Exploring the professional identity of health and social care staff via

experiences of interprofessional education and collaborative practice

Viktoria Cheryl Taz Joynes

Submitted in accordance with the

requirements for the degree of Doctor of

Philosophy

The University of Leeds

Leeds Institute of Medical Education

School of Medicine

September 2014

ii

The candidate confirms that the work submitted is his/her own and that

appropriate credit has been given where reference has been made to the

work of others.

This copy has been supplied on the understanding that it is copyright

material and that no quotation from the thesis may be published without

proper acknowledgement.

The right of Viktoria Cheryl Taz Joynes to be identified as Author of this

work has been asserted by her in accordance with the Copyright, Designs

and Patents Act 1988.

© 2014 The University of Leeds and Viktoria Cheryl Taz Joynes

iii

Acknowledgements

The work of this thesis is entirely my own but I would like to acknowledge Clair Atkinson who transcribed ten of the interviews for me. No PhD has ever been completed without the guidance of supervisors, and I extend my heartfelt thanks to both Professor Trudie Roberts and Sue Kilminster not only for their guidance but also for their extreme patience and willingness to bring a sociologist into the world of medical education. Acknowledgements are also due to Dr Rebecca O’Rourke who has been very generous with her time, giving me feedback on draft documents and presentations, and to my line-manager Dr Richard Fuller who has been extremely forgiving in the last couple of years allowing me to juggle PhD, work and home commitments, while also keeping me entertained along the way. Similarly if it had not been for the encouragements of my previous line-manager Trish Walker (alongside Trudie) I’m quite sure I would still be saying “I’m not quite ready to do a PhD yet”. I hope that the completion of this thesis justifies the belief that all of the individuals named above have shown in me. I also owe an immense thanks to all those professionals who gave freely of their time to respond to my surveys or take part in interviews and who made this research possible.

For extra-ordinary amounts of help in distributing my survey I shall ever be grateful to Shelley Fielden, and the proof-reading debt I own to Dr Gary Fry will doubtless never be paid, though I hope the wine helped. A huge number of colleagues - friends - have helped and advised me both academically and otherwise, but in particular Dr Chrissy Buse, Dr Rosa Mas-Giralt, Dr Alison Ledger, Dr Cait Dennis (with her knitted beard), Jools Symons, Nancy Davies, Elaine Brock, Chris Essen, Dr Anne-Marie Reid and Dr Naomi Quinton have all extended great kindnesses and shared their wisdom with me. Outside of academia I have been fortunate to have friends who take time to remind me that I don’t have to work ALL the time. Kate Henderson and Rick Steckles, who put up with my erratic commitment to the band, and to my whims when I am committed to it. Vicky and James Peck, who make sure I go out in Leeds at least once a year. Andy (and his ilk) and Ruth Burrell, Trudi and Jason Knight and Givvi and Percy who have all been there with ‘keep going hugs’ or words of encouragement at least several hundred times. In memory also of Violet and Trace – I miss you both terribly, but I hope I’ve done you proud reaching the end of this adventure. The music of Willie Dowling, Jon Poole, Givvi Flynn, CJ and Chris Catalyst (and combinations thereof) must also be acknowledged as the wonderful, stimulating and occasionally soothing soundtrack that got me through many hours of reading and writing.

Last of all, the biggest thanks go to my family, to whom this thesis is dedicated. To my dear friend Kate - pantoufle has always been pronounced ‘pan-too-full’. To my Mum, Cheryl, and Grandma, Zita, who have always supported me in any choice I have made. And most of all to Paul, who unwittingly married a PhD student, and Nikolas, our beautiful son who arrived during the journey and changed both our identities forever to ‘mum’ and ‘dad’. I love you all very much.

iv

Abstract

The study of professional identities in health and social care (H&SC) was

last prominent in the 1980s, with social theorists and policymakers taking

an interest the way in which identities and roles were formed. This thesis

proposes that the study of professional identity in H&SC requires renewed

attention, especially in the context of expectations that students will both

train and work across professional boundaries. Specifically, the thesis

questions whether experiences of interprofessional education (IPE) and

collaborative practice have any impact on perceptions of professional

identity for those working in H&SC, and examines how socialisation

processes influence the development of ‘professional identities’ as well as

considering the implications for patient care. A case study of a large-scale

interprofessional programme – the ALPS CETL – is also drawn upon to

examine the long-term impact of IPE initiatives on the identities and roles

of staff involved in interprofessional initiatives.

The empirical elements of this study consisted of surveys of practicing

(n=288) and academic (n=31) staff, and interviews with participants

drawn from the same groups (n=33). Drawing upon both thematic and

narrative analysis of the data, the thesis argues that previous

conceptualisations of professional identity aligned to a ‘whole’ profession

do not relate to the way in which H&SC professionals actually perceive

their identities. As respondents were far more likely to identify as being

part of a branch or sub-group of a profession, it is proposed here that the

concept of an ‘intra-professional identity’ is a more useful way to

conceptualise the identity of H&SC professionals. More ‘senior’

professionals appeared to be more comfortable with their own

professional identity, and with working across professional boundaries,

than junior colleagues. This has implications for the way in which IPE is

‘taught’. Finally, in order to address identified tensions between

professional identities and cross-professional working, it is proposed that

the concept of ‘interprofessional responsibility’ can and should be

incorporated into the professional identities of all H&SC staff.

v

Table of Contents

Authorship statement………………………………………………………….…………….ii

Acknowledgements…………………………………………………………………………..iii

Abstract……………………………………………………………………………………………..iv

Table of Contents……………………………………………………….…….……………..…..v

List of tables………………………………………………………………………………………xi

List of figures…………………………………………………………………………………….xii

Chapter One: The implications of interprofessional education for uni-

professional identity

1.1 Introduction……………………………………………………………………………...1

1.2 Background to the study…………………………………………………………….5

1.3 Terminology…………………………………………………………...…………………8

1.4 Research questions.…………………………………………………………………10

1.5 Context: IPE and understandings of ‘learning’ and ‘practice’………11

1.6 Approach to identity………………………………………………………………...12

1.7 ‘Interprofessional Responsibility’……………………………………………..13

1.8 Structure of the thesis……………………………………………………………...13

Chapter Two: ‘Professions’, Professional Status and Professional

Identity

2.1 Why defining ‘professional identity’ is important………………………16

2.2 The ‘place’ of professions in society……………………………………....….17

2.3 Identity and Identities……………………………………………………………...23

2.4 The professional identities of the health and social

care professions………………………………………………………………….…...33

2.41 The role of regulators and professional bodies……………….33

2.42 All professions are equal, but some are more equal

than others?.............................................................................................36

2.43 Medicine……………………………………………………………………….37

vi

2.44 Nursing…………………………………………………………………………42

2.45 Midwifery…………………………………………………………………......47

2.46 Physiotherapy……………………………………………………………….49

2.47 Occupational Therapy……………………………………………………50

2.48 Social Work…………………………………………………………………..53

2.49 The ‘younger’ professions and ‘assistants’………………………55

2.5 Uniform and signifiers……………………………………………………………...58

2.6 Occupational ideology and the notion of vocation……………………...61

2.7 Health and social care professions in competition: Silos

and Tribalism…………………………………………………………………………..61

2.8 Academic Identity……………………………………………………………………64

2.9 Summary…………………………………………………………………………………66

Chapter Three: Interprofessional Education: Policy, Literature and

Evidence

3.1 The literature searching process………………………………………………68

3.2 Government policies and curricula changes………………………………69

3.3 IPE as a dominant policy discourse…………………………………………...73

3.4 Existing literature reviews on IPE…………………………………………….77

3.41 ‘Forms’ of IPE………………………………………………………………..78

3.42 Exploring the evidence for the effectiveness of IPE…………79

3.5 IPE and learning theories…………………………………………………………87

3.6 Themes and variables in existing studies…………………………………..90

3.61 ‘Readiness for’, and attitudes towards,

interprofessional learning……………………………………………..92

3.62 Student evaluations of IPE initiatives……………………………..98

3.63 The timing of IPE…………………………………………………………..99

vii

3.64 Resources and organisation…………………………………………106

3.65 IPE delivered through e-Learning………………………………...108

3.66 Classroom versus clinical based IPE……………………………..111

3.7 Staff…………………………………………………………………………………........113

3.71 The need to support staff as IPE facilitators………………….114

3.72 Staff perspectives on IPE and collaborative practice……..115

3.8 IPE, socialisation and professional identity……………………………..118

3.9 What next for IPE?............................................................................................121

Chapter Four: Methodology

4.1 The importance of staff perspectives………………………………………124

4.11 The practicalities of gaining staff perspectives……………...125

4.2 Ethics…………………………………………………………………………………….126

4.3 Approach to research and mixing methods……………………………..127

4.4 Research phases…………………………………………………………………….128

4.5 Surveys………………………………………...........................................................129

4.51 Sampling…………………………………………………………………….133

4.52 Distribution………………………………………………………………...136

4.53 Respondent numbers…………………………………………………..137

4.6 Interviews……………………………………………………………………………..139

4.61 Interview participant numbers…………………………………….145

4.7 The ALPS CETL case study……………………………………………………...145

4.8 Analysis…………………………………………………………………………………149

viii

Chapter 5: Exploring the impact of a large-scale interprofessional

programme of work. Case study: The ALPS CETL

5.1 Introduction……………………………………………………………………….....154

5.2 The ALPS CETL……………………………………………………………………...154

5.21 The ALPS programme of work……………………………………..157

5.22 ALPS programme implementation……………………………….159

5.23 Context……………………………………………………………………….160

5.3 Programme Outcomes and Evaluation………………………………...….163

5.4 Collaborative Networks extension programme……………………….172

5.5 Evaluations of other large scale IPE programmes……………………174

5.6 Impact of the ALPS programme on staff………………………………….179

5.61 Themes from interview data………………………………………..181

5.61i Some partners benefitted more than others……………181

5.61ii IPE / collaborative practice happens anyway………….182

5.61iii Politics and existing working cultures as a barrier

to the implementation of IPE………………………………….185

5.61iv The ALPS legacy…………………………………………………….188

5.7 Summary……………………………………………………………………………….191

Chapter Six: Exploring perceptions of professional identity via

experiences of interprofessional education and collaborative practice

6.1 Introduction………………………………………………………………………….192

6.2 Survey respondents……………………………………………………………….193

6.21 Experiences of IPE………………………………………………………194

6.22 Opinions on IPE…………………………………………………………..198

6.23 Attitudes towards collaborative practice……………………...200

6.24 Perceptions of professional identity……………………………..203

ix

6.25 Relationship between perceptions of professional identity

and opinions of IPE……………………………………..………………205

6.26 Contact with students………………………………………………….206

6.3 Interview data………………………………………………………………………207

6.31 Conceptualisation of ‘own’ professional identity……..……207

6.32 Defining moments……………………………………………………….210

6.33 The ‘academic’ identity………………………………………………..213

6.34 Socialisation………………………………………………………………..216

6.35 ‘Strength’ of professional identity………………………………...217

6.36 The intra-professional identity…………………………………….220

6.37 Professional identity as context specific……………………….222

6.4 Conceptualisations of the professional identities of others………223

6.5 Experiences of IPE…………………………………………………………………229

6.6 Collaborative practice……………………………………………………..……..233

6.7 Professional identity, IPE and collaborative practice……………….236

6.8 Summary……………………………………………………………………………….240

Chapter Seven. Conclusion: Professional identity in an

interprofessional world

7.1 Introduction…………………………………………………………………………..242

7.2 Summary of Findings……………………………………………………………..244

7.3 Implications and recommendations………………………………………..256

7.31 Further implications and going forward……………………….259

x

Bibliography……………………………………………………………………………………..262

Glossary…………………………………………………………………………………………….299

Appendix 1: Research Protocol submitted to IRAS…………………………..302

Appendix 2: Approval letter received from Leeds East Research

Ethics Committee……………………………………………………………………………...306

Appendix 3: Approval letter received from the University

Research Ethics Committee………………………………………………………………310

Appendix 4: Survey tool for NHS staff………………………………………………311

Appendix 5: Survey tool for academic staff……………………………………...318

Appendix 6: Interview Schedule with NHS staff……………………………….326

Appendix 7: Interview Schedule with academic staff………………………328

Appendix 8: Structure of the ALPS Core Team…………………………………331

Appendix 9: ALPS Organisational Structure: Management

and Working Groups………………………………………………………………………...332

xi

List of Tables

Table 2.1: Professional Bodies in England, 2013…………………………………...35

Table 3.1: Interprofessional Education Joint Evaluation Team

classification of interprofessional education outcomes…………………………..83

Table 3.2: Summary of outcomes after classification of 107 IPE studies…84

Table 4.1: Professional background of survey respondents…………………138

Table 4.2: Current role or professional background of

interview respondents………………………………………………………………………..145

Table 5.1: ALPS Management and Working Groups and their function…161

Table 6.1: Types of IPE experienced by survey respondents………………..194

Table 6.2: Reported experience of IPE and self-rated seniority…………….195

Table 6.3: Experience of any IPE as part of professional training

by professional background………………………………………………………………..196

Table 6.4: Opinions of task specificity and respect between

professionals by professional group: There are tasks that my

profession is responsible for that no other profession can undertake……201

Table 6.5: Opinions of task specificity and respect between

professionals by professional group: I think there is a lot

of respect between professionals at work, regardless of which

profession they belong to……………………………………………………………………201

Table 6.6: Respondents’ opinions on professional identity and role

boundaries…………………………………………………………………………………………204

Table 6.7: Academic staff view on their own professional identity……….205

Table 6.8: NHS respondents’ level of contact with students on

placement………………………………………………………………………………………….206

Table 6.9: Key Findings from Empirical Research……………………..……...….241

xii

List of Figures

Figure 2.1: Machin et al’s (2011) Role identity equilibrium process………32

Figure 3.1: Cooper et al.’s (2001) Hierarchical levels of evaluation

of IPE interventions developed from Kirkpatrick (1967)……………………….80

Figure 6.1: Respondents’ ratings of how successful they believe IPE

can be in achieving certain aim...………………………………………………………….199

Figure 6.2: Respondents’ views on collaborative practice……………………200

Figure 6.3: NHS respondents’ attitudes towards collaborative

practice by self-rated level of seniority………………………………..……………….202

Figure 6.4: Respondents’ perceptions of professional identity……………..204

Figure 6.5: Common narrative elements in describing

professional roles……………………………………………………………………………….209

Figure 6.6: Common narrative elements in describing reasons

for becoming a H&SC academic……………………………………………………………214

1

Chapter One

The implications of interprofessional education for uni-

professional identity

1.1 Introduction

When thinking about health care provision in England in the twenty-first

century, it is impossible not to consider the myriad health and social care

(H&SC) professions involved in providing care and supporting service

users in both hospital and community settings. When systems of H&SC fail,

or fall below the expected standards of modern times, large inquiries often

ascribe the blame for such failings onto breakdowns in communication

between professionals or across professional boundaries (Kennedy 2001;

Laming 2003; Laming 2009; Francis 2013). The recommendations in such

reports often reiterate the need for effective communication and team-

working to achieve high quality and efficient care, and to ‘avoid tragedies’

(Cooper et al. 2004).

A brief study of the history of H&SC shows that placing an emphasis on

team-centred healthcare provision to ensure that service users receive the

best possible care has not always been the dominant model. The purpose

of ‘caring’ for patients did not exist until the eighteenth and nineteenth

centuries when hospitals moved away from being ‘instruments of

repression’ and started to focus on becoming ‘important institutions in the

delivery of healthcare’ (Waddington 2011, p145). The point at which those

involved in all H&SC occupations and professions started to co-operate,

that is to work collaboratively and interprofessionally, in order to provide

and improve service user care, is harder to locate. Many histories of the

various H&SC roles do exist, but are written with a focus less on

professional co-operation than on exploring and understanding their own

journey to ‘professionalisation’ (see for example Dingwall et al. 1988; Lane

2001). Leathard (1994) suggests that the background developments for

interprofessional working were laid in Britain in the 1970s, with the

2

‘pressure to go inter-professional’ increasing considerably as a result of

government policy from the mid-1980s, and ‘noticeably in the 1990s’ (p9).

Both the Local Government and Housing Act 1989 and the NHS and

Community Care Act 1990, for example, placed a great deal of emphasis on

inter-agency co-operation and information sharing between local authority

social services and healthcare providers. Consequently, successful H&SC

delivery in the modern health care system is now seen to depend upon the

effectiveness of a professional team made up of members from many

different professions. Subsequently there has been (and still is) much

debate about how to best educate and prepare health and social care

students so that when they graduate they are ready to work in teams

involving two or more professions. The primary aim of this thesis is to

explore the way in which H&SC professionals perceive their professional

identity and consider what interrelationship this has with their

interpretations and experiences of interprofessional education and

working.

The concept of ‘interprofessional education’ (IPE) emerged in the late

1980s. In the UK the concept developed alongside the formation of CAIPE

(Centre for the Advancement of Interprofessional Education), who were

responsible for the definition of IPE as it is now most commonly

recognised; where two or more professions ‘learn with, from and about

each other to improve collaboration and the quality of care’ (CAIPE 2002

from CAIPE website; Hammick 2007). Thus, ‘interprofessional education’

was considered a step further on than ‘shared-learning’ models, with the

focus of IPE being on collaborative practice and ‘on interactive learning

between [the] different professional groups involved’ (Leathard 1994,

p29). While questions remain over whether educating H&SC students

together using IPE results in graduates who are better able to work in

multi-professional teams than those receiving other forms of education

(Thistlethwaite 2012; Craddock et al. 2006; Pirrie et al. 1999), it is accurate

to claim that by the 2000s IPE had become the dominant discourse – ‘the

way forward’ – for improving H&SC provision. In the UK, this approach

3

was particularly prevalent, as can be seen in the developing policy

framework of the Health Act 1999 and Health and Social Care Act 2001

which, as Cooper et al. argue, paved the way for ‘requisite structural and

organisational change’ (2004, p179).

Such a change in emphasis toward IPE is also evident in ‘Tomorrow’s

Doctors’, the General Medical Council’s (GMC) ‘standards for knowledge

skills and behaviours that medical students should learn at UK medical

schools’ (GMC Website), first published in 1993. The 2003 version

stipulated that graduates needed be aware of both current developments

and the guiding principles in the NHS, including understanding ‘the

importance of working as a team within a multi-professional unit’ (GMC

2003, p15). The 2009 version of the same document was much more

explicit concerning the standard of interprofessional behaviour expected

from graduate doctors, highlighting that they need to be able to both learn

and work in multi-professional teams, understand and respect the

expertise and roles of other H&SC professionals as well as understand:

…the contribution that effective interdisciplinary teamworking

makes to the delivery of safe and high-quality care.

(GMC 2009, p27)

IPE is also a significant issue on the international policy agenda. In 1988

the World Health Organisation (WHO) published Learning Together to

Work Together for Health, an influential report which reviewed multi-

professional education initiatives throughout the world, and which

recommended that such educational initiatives should be promoted as a

complementary aspect to the education of health professionals (and

offered suggestions as to how such initiatives may be instigated). By 2010

the WHO had published a ‘Framework for Action on Interprofessional

Education and Collaborative Practice’, in which it is stated:

The WHO and its partners recognize interprofessional

collaboration in education and practice as an innovative strategy

4

that will play an important part in mitigating the global health

workforce crisis. (WHO 2010, p7)

However, while answering this call to ‘interprofessional arms’, it is

recognised that H&SC professionals must still be trained to their own

regulatory body’s professional standards, and be able to perform their own

roles, carrying out profession-specific tasks that they are in the healthcare

organisations to provide; they must work in an interprofessional way (that

is, collaboratively, with other professions) while in essence ‘maintaining’

their own ‘discrete’ professional identity (Pirrie et al. 1999; Hornby and

Atkins 2000). In order to understand ‘hindrances’ to collaborative,

interprofessional working it is therefore important to understand the

concepts of ‘identity, role and boundaries’ (Hornby and Atkins 2000, p97).

The notion that professional identity partly develops through a

‘socialisation’ process in the health and social care professions has become

a popular theory, explored in various ethnographic studies of the

professions since the 1960s, and perhaps most famously in health and

social care in Becker et al.’s 1961 study ‘Boys in White: student culture in

medical school’, although it is a concept that can be applied to all H&SC

professions. Socialisation into a profession is understood to be a complex

process, but one of the key parts is exposure to professional behaviour and

interaction in the ‘real world’, through what Thompson and Ryan (1996)

refer to as ‘fieldwork’ experiences, but what in the UK are more commonly

referred to as ‘placements’. Nevertheless, while socialisation is a

recognised part of professional identity formation, the concept of

professional identity (explored in detail in Chapter Two) is contested and

debated, with no single, agreed definition.

Olckers et al. (2007 p2) argue that professional identity is widely accepted

to be associated with the way professions perform their roles and that

developing such an identity is often associated with the ‘internalising’ of

‘professionalism’. Notably, conceptualisations of professional identity are

commonly linked to single-professions, so that people performing those

5

roles have such identities as, for example, ‘doctors’, ‘nurses’, ‘midwives’ or

‘social workers’. As such, professional identities have been depicted as a

‘barrier’ to interprofessional education and working (see Elston and

Holloway 2001). However, more latterly an emerging tension in the

academic debate surrounding IPE and professional identity stems from IPE

being portrayed as something that strengthens individual professional

identities (see Jakobsen et al. 2011). Chapter Three explores in depth the

evidence in the literature that supports both sides of this argument.

In this thesis, I suggest that in order to enable H&SC professionals to better

work together, it is fundamentally important to understand what

relationship exists between IPE and professional identity, because of the

impact that professional roles and (inter)professional working have on

service user care. The need to understand this relationship is recognised

by Cameron (2011, p53), who suggests there is a:

…need to move beyond the current focus on the role of

education, training and regulation which structure professional

boundaries to appreciate the ‘human and social aspects’…in order

to understand how individual professionals perceive and

experiences the boundaries between professional groups.

To reiterate, exploring the interrelationship between perceptions of

professional identity and the way in which H&SC professionals interpret

and experience interprofessional education and working is therefore the

primary objective of this thesis.

1.2 Background to the study

I first became aware of the concept of ‘interprofessional education’ when I

started working for the Assessment and Learning in Practice Settings

(ALPS) Centre for Excellence in Teaching and Learning (CETL). ALPS was

initially funded as a five year programme by the Higher Education Funding

Council for England (HEFCE) as one of 74 CETLs in the country. ALPS

6

involved sixteen H&SC professions across five Higher Education

Institutions (HEIs) in West Yorkshire, as well as partnering with

professional bodies, the (then) West Yorkshire and the Humber Strategic

Health Authority (WYHSHA) and practice networks. The ALPS mission

was:

to explore ways which ensured that students from courses in

Health and Social Care graduate fully equipped to perform

confidently and competently at the start of their professional

careers. (ALPS Website)

There were many strands to the ALPS programme of work, but one of the

main aspects was to develop a series of ‘Common Competency’ maps that

were relevant to all sixteen H&SC professions involved. From these maps, a

series of assessment tools was developed for students to use while out on

practice placement, with one of the key features of the tools being that they

involved an element of interprofessional feedback – i.e. the student would

receive feedback from either staff or students in professions other than the

one they were training to join.

While already aware of a body of literature on the sociology of the

professions, it was during the development phase of the ALPS maps and

tools that I became conscious of academic debates on the ‘tribalistic’ nature

of H&SC professions and the way in which allegiances to professions were

sometimes depicted as a barrier to people from different professions

working successfully together (Carlisle et al. 2004; Smith and Roberts

2005). As a result, I questioned what impact, if any, a long-term large-scale

interprofessional project such as ALPS would have on the professionals

who were involved in it. In particular I was interested on the impact of

such a project on staff involved in developing and delivering it, rather than

on students taking part in the programme. This was because I considered

that some of the opinions expressed by staff involved in ALPS were

indicative that their opinions could be one of the barriers to an

interprofessional programme of work being implemented successfully.

7

Resultantly, I wanted to further explore what IPE qualified staff had

themselves experienced, in order to consider the impact of these

experiences on IPE programmes they were subsequently involved in

facilitating.

As is discussed in Chapter Three, most of the existing literature on IPE

focuses on students, including a large body of work on their ‘readiness’ or

willingness to engage with interprofessional material (see for example the

works of Parsell and Bligh 1999; McFadyen et al. 2006). The literature that

does concentrate on staff perceptions of IPE most commonly focuses on the

organisational structures that restrict interprofessional initiatives and on

ways to address this (Deutschlander et al. 2012; Salfi et al. 2012; Reeves et

al. 2007). However, there is a growing recognition of the need for staff to be

‘signed up’ to the idea of IPE and to be well-trained for it to ‘work’

(Williamson et al. 2011; Anderson et al. 2011). As socialisation is such an

important part of developing professional role and identity (see Chapter 2),

for IPE to achieve its aims of improving service user care by preparing

students to communicate and work more effectively in interprofessional

teams, part of the success of this process will rest with those doing the

‘socialisation’.

Meerabeau (1998, p83) identifies two broad analytical approaches to

occupational socialisation:

1. the induction approach, which derives from functionalism,

focuses on the acquisition of professional roles, but takes

motivation for granted and neglects the expectations which

individuals bring with them…

2. the reaction approach, which analyses how students react to

their educational experiences, explores their motivation, and

regards the training institution as an independent social unit.

However, neither of these approaches encompasses the entire approach of

this thesis. While the acquisition of professional roles through both formal

and informal learning is a concern of this research, the impact of pre-

8

existing ideas concerning professional identities is viewed as an important

part of identity formation (Chapters Two and Six). The reaction of students

to educational experiences of students are also understood here as key to

the socialisation experience, but this thesis is additionally concerned with

exploring the opinions of those responsible (in part at least) for ‘doing’ the

socialisation, the practicing and academic staff who influence the

experiences of students.

The influence of staff as professionals, both in an academic and practice

environment is potentially very great, as they will likely be the first role

models for students in their chosen profession. I therefore argue that the

focus of this thesis, which involves understanding the attitudes of (some)

qualified H&SC staff towards professional identity and IPE, that may have

arisen as a result of experiences of IPE, is an extremely important area of

research, because it may yield knowledge about the successful

implementation of initiatives that could lead to more effective collaborative

practice.

Another advantage to focusing the research on qualified H&SC staff is that

these groups already possess a ‘professional identity’ – that is, an identity

as a ‘practicing professional’. Focusing the research on students would be

complicated and far more questionable in terms of its results, as students

are likely to be still developing their ‘professional identity[ies]’ and, at the

very least, would have a dual identity associated with being a ‘student’ of a

‘profession’. As such, to explore potential relationships between

perceptions of professional identity and IPE, it was more appropriate to

focus the research on qualified staff, and offers a different approach to the

study of socialisation than the two previously identified by Meerabeau

(1998).

1.3 Terminology

At this juncture it is important to define some of the terminology that will

be used throughout this thesis. The terms ‘interprofessional’, ‘multi-

9

professional’ and ‘multi-disciplinary’ are sometimes used interchangeably,

as if they describe the same phenomenon (Craddock et al. 2006, p221).

However, as already discussed, the term ‘interprofessional’ does have a

specific meaning when applied to education and is now commonly

understood and accepted to refer to occasions where two or more

professions ‘learn with, from and about each other to improve

collaboration and the quality of care’ (CAIPE 2002). It is the emphasis on

learning with and from one another to which I refer whenever the term

‘interprofessional’ is used in this thesis. The concept of ‘multiprofessional’ I

define as when more than one profession contributes to an educational

initiative or work practice, but where there is little or no interaction or

learning between the professions. Nevertheless, as Leathard (1994, 2003)

indicates with a long list of alternative terminology, contrasting definitions

of ‘multiprofessional’ and ‘interprofessional’ have been described as a

‘semantic quagmire’ (Craddock et al. 2006, p221, citing Leathard 1991 and

McPherson et al. 2001). As such, even though I am using ‘interprofessional’

and ‘multiprofessional’ to mean separate things, unless it is explicitly

stated, it cannot be assumed that other authors make the same distinction.

Applying the term ‘interprofessional’ to working is not so clear cut, with

there being no suggestion that ‘interprofessional working’ is in any way

different or distinct from ‘multiprofessional working’. However, the

concept of interprofessional ‘collaborative practice’ could be argued to

describe more usefully the intended outcome of IPE, with the interactional

nature of IPE more likely to enhance ‘collaborative practice’ than either

multiprofessional or uniprofessional education (Reeves et al. 2008, p3). It

is the term ‘collaborative practice’ that I shall therefore use throughout this

thesis to describe meaningful interprofessional working.

Lastly, I have throughout this chapter referred to all health and social care

occupations as ‘professions’. As will be discussed in Chapter Two, this label

can be somewhat problematic, with a long history of debate over which

occupations are entitled to such a label (and accompanying status).

Nevertheless, for ease of discussion I shall continue to use ‘professions’ and

10

‘professionals’ as the collective label for those working in health and social

care, while the detail of how accurate this is discussed in the following

chapter.

1.4 Research questions

The overarching aim of this study is to understand how practicing H&SC

professionals perceive their own professional identities and how this

relates to what they consider their professional roles and boundaries,

which will be addressed by answering the following inter-related research

questions:

1. How do practicing H&SC staff conceptualise their professional

identity, and the professional identity of other professions with whom they

work or learn?

2. Do practicing H&SC staff perceive that ‘professional identities’ are

reinforced, challenged or changed by interprofessional education and / or

collaborative practice?

3. What implications do conceptualisations of professional identities

and IPE have for the implementation of educational initiatives aimed at

improving teamwork between professions for the ultimate aim of

improving service user care?

Using a case study approach, one further research question is addressed to

help answer the three main research questions cited above:

4. What impact does the implementation of a large-scale

interprofessional programme have on staff involved in delivering the

programme?

The study is also concerned with understanding how health and social care

staff regard IPE; this is based not only upon their experiences but also upon

their perceptions (which may not be based on any experience of IPE). In

the analysis, attention is given to whether there is a link between

perceptions of interprofessional experiences and perceptions of

11

professional identity. The study was started under the premise that it is

possible that there is no ‘link’ between professional identity perception and

IPE / collaborative practice, but that this itself would have implications for

the way that IPE is conceptualised and consequently how it is taught. The

study was not therefore designed to look explicitly for a ‘link’; rather, it is

concerned with exploring whether it is possible to establish such a link. As

such, the research is exploratory in nature and the methods adopted

(discussed in Chapter Four) reflect this. The nature of undertaking

‘identity’ as a research topic also means that the study makes no claims that

the findings could be generalised to the entire H&SC staff population.

Instead, individual perspectives are explored that, if contributing to a

‘cohesive picture’ of interpretations of professional identity, may have

implications for the way IPE is developed and delivered.

1.5 Context: IPE and understandings of ‘learning’ and ‘practice’

The premise of interprofessional education – IPE, the theories and evidence

underlying approaches to it, are covered in detail in Chapter Three.

However there are also associated concepts that will benefit from

discussion at this juncture, as their definition impacts upon understandings

and interpretations of any form of educational initiative, but in this

instance IPE. In particular, the terms ‘learning’ and ‘practice’ require

definition, although the task of defining each of these could, and indeed has

in the past, taken entire chapters and books. The definitions given here are

therefore necessarily brief, and are not intended as a complete summary of

the much wider academic debates which surround their use, but are

presented here only to outline the context in which the terms are

understood and used in this thesis.

Following a sociocultural perspective, professional learning is understood

here through the ‘participational’ metaphor of learning, where ‘knowing

is…situated in activity and therefore is particular to settings and

communities’ (Fenwick and Nerland 2014, p3). This is in contrast to the

12

conceptualisation of learning as ‘acquisitional’, that is as an individual

experience that involves ‘the acquisition of disciplinary and problem-

solving competencies in knowing what to do, how and why’ (Fenwick and

Nerland 2014, p2). Simultaneously, and from the same sociocultural

perspective, ‘practice’ is understood to involve ‘practitioners knowing and

learning in everyday activity’ (Fenwick and Nerland 2014, p3). Thus it is

possible to understand that ‘learning’ cannot be separated from ‘practice’

because from this perspective one necessarily involves the other.

The purpose in this thesis of using this approach to ‘learning’ and ‘practice’

is that they highlight the importance of understanding ‘situatedness’; that

is, they are based on the premise that the social situation and the material

setting must be considered as the context for ‘knowing, working, learning

and innovating’ (Gherardi 2014, p12). Such methods highlight the

extremely complex and challenging nature of understanding an educational

innovation such as IPE, which is intended to result in organisational

change. While, as has been acknowledged, the sociocultural

understandings used here are only one of a number of interpretations of

‘learning’ and ‘practice’, they do raise questions about the extent to which

IPE is based upon an ‘over-simplified understanding of work, learning and

change’ (Kilminster and Zukas 2007). Using such a lens is thus particularly

useful in a project concerned with exploring the impact of IPE on

professional identities, which must be understood to involve a web of

enmeshed activity and not a straightforward, linear relationship. It is in

this context which IPE and professional identity are discussed throughout

this thesis.

1.6 Approach to ‘identity’

The approach taken to identity in this thesis is a sociological one. While

there is much work grounded in psychology on the topic of identity, such

approaches tend to focus on the individual conceptualisations of ‘the self’,

where sociological perspectives are concentrated around the notion that

13

identity is ‘fundamentally social and collective’ (Lawler 2008, p1). The

focus of this thesis concerns ‘professional identity’, that is an identity that

can only be earned through membership of a group (as one of many,

simultaneous ‘identities’ that an individual may possess at any given time).

As such it was important for the theoretical approach to identity to be able

to provide explanation for the significance of an individual being labelled as

a member of a professional group, and simultaneously, as not being

labelled as something else. This discussion is elaborated in detail in

Chapter Two.

1.7 ‘Interprofessional Responsibility’

The notion of ‘interprofessional responsibility’ is an emerging theme of the

work of the entire thesis. The results of the literature review, case study

and interview data all raise questions about the extent to which

professions – either individually or collectively depending on the context,

have a responsibility to engage with, share best practice concerning, or

educate their own members about, interprofessional education and

collaborative practice. In the final chapter, the thesis also questions the

extent to which individual H&SC professionals should view

‘interprofessional responsibility’ as part of their own professional identity,

and the extent to which this may be achievable. The term is defined here,

then, as any instance where an individual professional or profession as a

whole could be perceived to have a responsibility concerning

interprofessional behaviour.

1.8 Structure of the thesis

The arguments of this thesis are presented in the following order:

Chapter Two outlines dominant theories concerning professional identity.

It is argued that to understand concepts of professional identity, it is first

essential to understand how ‘professions’ have been conceptualised and

14

how, through earning the status of a profession, occupations adopt and

present a professional identity. Attention is given to various theories of

identity, and how it is possible for professional identities to be viewed as

tribalistic or even as ‘subcultures’, resulting in the need for students to be

socialised into their profession by ‘good’ role models. The extent to which

members of health and social care professions have been able to lay claim

to a professional identity is also discussed.

Chapter Three presents an extensive review of the literature on IPE, and

critically evaluates previous research and theories concerning IPE. It

argues that a large amount of attention has been given to work on student

‘readiness’ for interprofessional learning and staff and student perspectives

about IPE, at the expense of developing evidence-based practice for IPE

interventions. The chapter then explores existing research on staff

perspectives on IPE, and discusses the outcomes, relevance and

implications of existing studies linking professional identity to IPE. Finally

it questions whether there is a need for ‘interprofessional responsibility’ to

be incorporated into individual professional identities, and discusses the

potential implications of this for introducing IPE into curricula.

Chapter Four discusses in detail the methodologies used to complete the

empirical elements of the research – namely, surveys, semi-structured

interviews, and a case study, and outlines the methods used to analyse the

collected data.

Chapter Five presents a case study of the ALPS CETL. It describes the aims

and objectives of the CETL and goes on to explore the evidence for how

successful ALPS was at achieving its aims relating to the introduction of

interprofessional teaching and assessment. Using interview data collected

for this study, it then examines what impact staff involved in the CETL

perceived that being involved in a large-scale interprofessional programme

had on them as individuals, their departments and the institutions which

they work for. In this chapter, the question of ‘interprofessional

responsibility’ is raised regarding whether larger professions should invite

15

and include smaller professions to take part in interprofessional initiatives,

in order to ensure that best-practice is shared as widely as possible.

Chapter Six presents further findings from the empirical research carried

out specifically for this thesis. After outlining some of the key findings from

the survey, it outlines several recurring narratives which emerged from the

interviews, and relates these to the literature discussed in earlier chapters.

In particular, attention is paid to the notions of ‘intra-professional’ and

‘academic / teaching’ identities, as well as to the suggestion that

professional identity can be a hindrance to patient care. It also returns to

one of the key themes of this thesis, the notion of the need to incorporate

‘interprofessional responsibility’ into individual professional identities.

Chapter Seven is the concluding chapter which summarises the key findings

and central arguments of the thesis, and discusses the possibilities and

directions for future research. While recognising that the narratives told

around professional identities and experiences of IPE were unique to the

participants of this research, it also proposes that there are broader

implications for the findings of this work, for both the introduction of IPE

into curricula and also for the further study of professional identities in

H&SC.

16

Chapter Two

‘Professions’, Professional Status and Professional Identity

…all professionals are laymen to the other professions…

-Harold Perkin (2002)

This chapter explores all aspects of ‘professional identity’, by first

explaining why professional identity and status are so important, and still

worthy of study. It then discusses in detail how ‘identity’ and ‘professional

identities’ have been theoretically conceptualised, before going on to

explore how the specific professional identities of a number of different

H&SC professions have developed by looking briefly at their history and

claims to a ‘professional identity’. Finally, the chapter explores some

notable points for consideration arising in the study of identity such as the

concepts of ‘occupational ideology and vocation’ and the issues of tribalism

and silos working.

2.1 Why defining ‘professional identity’ is important

Exploring and explaining identity has been a key concern of social theorists

for many years. Nevertheless, as will be made evident in this discussion,

there is no consensus around what identity ‘is’, and no agreed, simple

definition that encapsulates ‘an’ identity. However, despite differences in

interpretations of the reasons behind it (such as individual, social and

cultural transformations), much work exploring the subject recognises that

‘identities’ change over time and context, and are dependent upon

interpretations made by the self and others. These ideas play a key role in

trying to understand how people define, and interpret, their own

‘professional identity’.

As made clear in this chapter, and previously, ‘identity’ is very much

associated with situation – that is, with the time and space in which it is

being viewed or experienced. The ‘professional identity’ of a doctor, nurse

17

or any other H&SC professional is likely to vary greatly from country to

country, as it will be associated with the educational systems and expected

role that each profession fulfils in each location. As such, unless otherwise

specified, the majority of the following discussion on professions and their

history refers specifically to the UK, where this research was undertaken,

and is therefore most relevant to later analysis and discussion of empirical

data collected specifically for this project.

Why then is understanding ‘professional identity’ so important? As

Woodward (2002) suggests, being able to ‘lay claim to an identity’

distinguishes us from others; it not only ‘marks us out as sharing culture

[or] experience with those whom we identify’ but also results in the ability

to exclude or ‘exile’ those who do not share the same identity (p156).

McDonald (2004) also notes that sharing a common, stable identity can

advance practice for H&SC professionals and that conversely unmanaged,

unstable identities can lead to feelings of disempowerment. Being able to

‘lay claim’ to a ‘professional identity’ is therefore important because of

what such an identity means to both individuals and professional practice;

and so to understand why professional identity is so important, it is firstly

necessary to understand what it means to be a member of a ‘profession’.

2.2 The ‘place’ of professions in society

To be considered ‘professional’ has, historically at least, been considered

desirable for occupations and individuals, because of both the status and

the privileged position in society which professionals are afforded (Hughes

1971). However the concept of the profession/al is itself is historically

specific and has long-been criticised as uncritical reproduction of the

knowledge of those attempting to define it, usually ‘professionals’

themselves (Witz 1992; Brante 1988). These critiques, stemming from

both sociological and feminist literature provide for some interesting

academic debate, but do not detract from the ‘desirability’ of a professional

status for occupations. Perkin suggests that the notion of a ‘professional

18

society’ is more complicated than being about a society dominated by

professionals, with professional hierarchies transcending traditional class

boundaries and allowing many occupations to aspire to professional status,

with the consequence that many jobs have ‘become subject to specialized

training’, allowing them to ‘claim expertise beyond the common sense of

the layman’ (2002, p3). It is argued that being able to claim such a status

brings rewards – a claim examined here – which itself makes professional

status and identity as a ‘professional’ desirable. Macdonald suggests that:

The professional project is intended to secure for its members

economic and social advantage, thus achieving upward social

mobility. (1995, p63)

While Becker et al. also propose:

In our society, among the most desired and admired statuses is to

be a member of a profession. Such status is attained not by going

into the woods for intense, but brief, ordeals of initiation into adult

mysteries, but by a long course of professional instruction and

supervised practice. (1961, p4)

To achieve a professional status is therefore seen as desirable for

individuals; but to do this they must first earn membership of an

occupation which itself is regarded as a ‘profession’. The achievement of

‘professional status’ by occupations has in itself been the topic of

sociological study and debate for a number of years, and is worthy of some

attention at this juncture.

Many academic works have attempted to define ‘professions’ by the ‘traits’

they possess, with the consequence that ‘professional status’ is seen as

being achieved once an occupation can lay claim to possessing such

attributes. This body of work, often referred to as the ‘trait approach’,

defines professions as possessing ‘systematic theory, authority, community

sanction, ethical codes and a culture’ (Greenwood 1957, and similarly

Horobin 1983 and Atkinson 1983). The trait approach is, however, widely

regarded as problematic due to the way in which it delineates professions

19

with an ‘idealized conception of the characteristics of the archetypal

professions – medicine and law’ (Abbott & Meerabeau 1998, p4). Wilding

suggests that a key problem in defining ‘professional’ using the trait

approach is that there seems to be an ‘endless search for one true

profession, an archetypal, ideal type…exuding the very esse of

professionalism’ (1982, p3), whilst Freidson argues that one cannot define

a ‘profession’ by ‘struggling to formulate a single definition which is hoped

to win the day’ (1983, p35). In a later in-depth discussion on ‘identifying

professions’ Freidson also suggests that the problem of definition is created

by:

…attempting to treat profession as if it were a generic concept

rather than a changing historic concept with particularistic roots

in those industrial nations that are strongly influenced by Anglo-

American institutions. (1986, p32)

Ultimately, using a trait approach has been dismissed as unhelpful because

it focuses on what professionals claim to do (Abbott and Meerabeau 1998,

p4). Abbott and Meerabeau propose that alternative conceptualisations

are considered, such as Becker’s (1971) proposal that the concept of

‘profession’ is a symbol attached to some occupations but not others, or

Freidson’s (1986) suggestion that it is more helpful to use the notion of

‘professionalism’ as used in practice. However, whilst using a trait

approach may now be considered an inappropriate and misleading way to

define the professions, it remains important and must be referred to

because of the considerable contribution it has made to academic debate

around the subject. It also highlights how professions have been viewed

historically, which is important when trying to understand the attributes to

which occupations may have been expected to aspire in order to become

professions.

Whether one accepts that a set of ‘traits’ can define a profession as a full or

partial list, there is nonetheless one attribute referred to as defining access

to a professional status above all others: knowledge. However, as already

20

discussed, it is not just access to facts and figures that turn a layman into a

professional; it is the training in how to use and apply them, what Freidson

(1986) defines as ‘formal knowledge’. Today, it could be argued that the

notion of the ‘all-knowing professional’ is far less stable than in the past,

because of the way in which the internet can be used to acquire

information, something previously only in the domain of professionals.

The ‘systematic theory’ owned only by professionals in the past is now

often available for all to access, but it is the training received by

professionals that still provides the distinction for what can be done with

such information, turning it in to usable skills and knowledge. Eve and

Hodgkin (1997) add to this by highlighting that ‘professionalism’ is about

using this knowledge in the ‘affairs of others’:

A professional task is one which requires the exercise of

discretion or initiative on behalf of another in a situation of

complexity. (p70)

However, they suggest that, ideally, the definition of a professional task

would be:

…where one person exercises discretion with another in a

situation of complexity ensuring so far as possible that all

necessary information, together with any financial incentives and

constraints which the professional may be under, are transparent

to the patient or client.

(Eve and Hodgkin 1997, p84, original emphasis)

Although they recognise that such a feat is not likely to be achieved easily,

and would be reliant upon ‘sophisticated information technology’. But this,

they suggest, is the way that professionalism will adapt and survive in a

‘rapidly changing world’ (Eve and Hodgkin 1997, p84). While it is clear

that this is an ‘ideal type’ description of the role performed by

professionals, it does highlight the significance of other characteristics that

arise when professional knowledge is used: trust and power.

21

Giddens proposes that trust is necessarily involved in a relationship where

one member of that relationship has much less access to knowledge than

the other:

Trust is only demanded where there is ignorance – either of the

knowledge claims of technical experts of the thoughts and

intentions of intimates upon whom a person relies…Thus trust is

much less a leap to commitment than a tacit acceptance of

circumstances in which other alternatives are largely foreclosed.

(1990, pp89-90)

The necessity for a trust relationship between professionals and their

clients (or patients) can be seen as an example of what Weber (and

subsequently Parsons) refer to as a ‘legitimation’ of power (Dingwall 1983,

p2). Foucault interprets the process by which professionals achieve power

and dominance. He describes that ‘discipline’ has a double meaning, being

both a result of formal knowledge and a ‘consequence of its application to

the affairs of others’, and results in power being gained through the

‘normalization’ of such ‘disciplines’ as health care (amongst others)

(Freidson 1986, p6). In terms of financial reward for such knowledge,

Perkin (2002) argues that members of professions are no different from

any other members of society (from the ‘richest capitalist’ to the ‘most

unskilled labourer’) when it comes to the ‘economic battle’ for their

services, but that the difference for professionals is that:

…beyond the layman’s knowledge or judgement, impossible to pin

down or fault even when it fails, and which therefore must be

taken on trust…[the professional] is dependent on persuading the

client to accept his valuation of the service rather than allowing it

to find its own value in the marketplace. (p117)

The consequence of doing this successfully, Perkin argues, is what leads to

professionals rising above the ‘economic battle’, with the result that it is in

the interest of those afforded this status to:

22

play down class conflict…[and] play up mutual service and

responsibility and the efficient use of human resources.

(2002, p117)

Trust and power, it could therefore be argued, are a desirable part of being

a professional, allowing freedom and control over their own work. On the

other hand, it could be suggested that the consequence of being afforded

trust and power are the responsibilities of holding such status, of being

seen always to do the ‘right’ thing and to take the blame when things go

wrong. Freidson also argues that the relationship between professional

status and power represents two diametrically opposed views; the first,

following Foucault and others, that it is the professions who are rewarded

by dominance and as such have a great deal of influence on state policy and

on the affairs of individuals; the second, that professions are ‘passive

instruments of capital, the state or their individual clients’ and that as such

they have little or no control over policy or their own affairs (Freidson

1994, p31).

For the purposes of this thesis, I would suggest that the first of these

theories is still the most relevant to the health and social care professions

in the UK today. Whilst it may be true that today people are more inclined

to question professionals (and those in positions of power), it is still the

case that health and social care occupations are regulated by professional

and regulatory bodies made up of their own members (albeit often with

representation from other professions). This gives those in H&SC the

ability to define their own ‘systematic theory’ and ‘ethical codes’, and

suggests that they are not entirely passive instruments of the state. On an

individual level, H&SC professionals can also be seen to hold power in the

sense that clients / patients who need expert advice and opinion must

consult professionals when they perceive there is no alternative, and also

must accept their diagnosis or judgement without knowing if they are

being given the ‘right’ information. The nature of this type of contact with

clients is what leads to the need for a code of ethics (Millerson 1964, p153).

23

Whilst association with certain attributes (such as having a ‘code of ethics’

or ‘systematic theory’) may define (or be a result of) the

‘professionalisation’ of an occupation, there is a further distinction to be

drawn between the occupation as a ‘profession’, and the individual as a

‘professional’ who displays ‘professionalism’. As Johnson (1972) suggests:

It is not at all clear then that professionalisation refers to the same

process as occurs when claims for professional status are made.

However, professionalism is a successful ideology and as such has

entered the political vocabulary of a wide range of occupational

groups who compete for status and income. (p32, emphasis added)

As an individual, being a member of a profession dictates the need for a

certain standard of conduct to be met, and by adhering to and displaying

that standard through one’s ‘professionalism’, an identity as a professional

can be gained and reinforced (or, in cases where the standards are not met,

denied). Nevertheless, understanding the various interpretations and

nuances of the terms ‘professional’ and ‘professionalism’ still only

represents half the story of why ‘professional identity’ remains both

difficult to describe and define and, the key to understanding professional

roles. The following section explores some theories of identity in order to

complete this task.

2.3 Identity and Identities

Identity and identities have long been considered to be ‘socially produced’,

with a variety of interpretations focusing on the ‘mechanisms’ by which

identity can be ‘achieved’ (Lawler 2008, p1). For George Mead, whose

approach came to be known as symbolic interactionism, the self is

something that develops: ‘it is not initially there, at birth, but arises in the

process of social experience and activity’ (1934, p135). For Mead, the ‘self’

could only be understood and given meaning in relation to other people,

based upon the interactions with others and the meanings given to those

(inter)actions. Indeed, for Mead, the ‘self’ did not exist without

24

communication, and he proposed that the self develops as part of the

communicative process, suggesting that: ‘it is impossible to conceive of a

self arising outside of social experience’ (1934, p140). Developing the

arguments of Cooley and James, Mead proposed there was a distinction

between the ‘I’ and the ‘me’, with the process that links the two and

develops the ‘self’ being the interactions between the internal ‘inner

dramatization, by the individual’ and the external ‘conversation of

significant gestures’ with ‘individuals belonging to the same society’ (1934,

p173):

Thus ’I’ understand myself through imagining how I am understood

by others – as ‘me’. (Woodward 2002, p9)

Consequently any meaning given to the ‘self’ (our ‘self-consciousness’ – and

therefore our identity, and our interpretation of the identity of others)

comes through a shared understanding of language.

Mead’s interpretation of the ‘self’ also allows for the possibility that the

‘self’ can have multiple identities, so that in different social contexts we can,

or are required to, ‘present different selves’ (Woodward 2002, p9), a theme

also developed by Goffman. Goffman (1959) contributed to discussions on

the interpretation of identity by suggesting that the ‘self’ can be both

presented and interpreted through a series of signs. Using the metaphor of

the stage to explain how people ‘perform’ or ‘act’ their ‘roles’ in a variety of

‘settings’, Goffman suggested that:

A setting tends to stay put, geographically speaking, so that those

who would use a particular setting as part of their performance

cannot begin their act until they have brought themselves to the

appropriate place and must terminate their performance when

they leave it. (1959, p33)

Using this interpretation, one can understand how it is possible to have, or

to be seen to have, different identities in different places; thus one can have

a different identity at work than in one’s personal life. As with Mead,

Goffman’s work also has implications for the notion that identity is open to

25

interpretation, and that the ‘self’ that one hopes to present is not

necessarily interpreted correctly by the ‘audience’. Goffman talks about the

subsequent need for ‘impression management’ to enable a ‘performer’ to

successfully ‘stage a character’ (Goffman 1959, p203), but he also

acknowledges that under certain circumstances, ‘misrepresentation’ may

be desired by the ‘performer[s]’ (Goffman 1959, p65 - 73) – for example, by

acting as if everything is fine when there is a problem the ‘performer’

wishes to conceal from the ‘audience’. The theories that both Mead and

Goffman offer also suggest that identity is not static; it can be situation and

context specific, and as such individuals can have multiple, simultaneous

identities.

Garfinkel’s ethnomethodological approach also has relevance to theories of

identity. Garfinkel proposed that the self is produced through social

interaction, and as such, the ‘self’ can change from moment to moment,

dependent upon whom the person is interacting with, the context of that

interaction, and the (meaningful production of) interpretation placed upon

that interaction by the social actors involved. However, in attempting to

define ‘the factual world’, Garfinkel was concerned to use only the

‘observable-and-reportable’ to describe how people organize and make

sense of their lives and produce and present their identities (Garfinkel

1967). Garfinkel’s work has been criticised because of its tendency to

describe what we already know, and its failure to take a firm theoretical

position (Woodward 2002, p12), but it does further support the notion that

one person (or self) can have multiple and simultaneous identities.

More recently, academic narrative on identity has turned its attention to

the extent to which people are able to shape, and actively participate in

constructing their own identities (Woodward 2002; Calhoun 1994). Michel

Foucault’s (1988) work on the ‘technologies of the self’, explored how

subjects ‘actively constitute themselves, through engaging in the cultural

practices of everyday life’ (Woodward 2002, p30). Giddens (1991)

discusses the reflexive nature of the self in an age of modernity, suggesting

that coherent but continuously revised biographical narratives take place

26

in the ‘context of multiple-choice filtered through abstract systems’ (p5).

He goes on to suggest that the question ‘“how shall I live?” has to be

answered in day-to-day decisions about how to behave’ (p14). Similarly,

Bauman states:

One becomes aware that ‘belonging’ and ‘identity’ are not cut in

rock…that they are eminently negotiable and revocable; and that

one’s own decisions, the steps one takes, the way one acts…are

crucial factors of both. (2004, p11)

It is therefore possible to argue at a theoretical extreme that identity is not

only constructed but self-constructed, that we can appear as we desire to

appear in different places and at different times, and that we can, to some

extent, control this through the choices that we make and through our

behaviour. This point needs to be considered alongside the ‘structural’

influences on behaviour such as culture, which are particularly important

when considering those aspects of identity related to professional

behaviour. However, Calhoun indicates that the strength of using theories

grounded in social constructionism (that is theories with an emphasis on

the socially created nature of social life - such as those presented here) is

that ‘they challenge…the idea that identity is given naturally and the idea

that it is produced purely by acts of individual will’ (1994 p13, emphasis

added). Such theories provide useful lenses through which to examine

perceptions of professional identity and identities.

A further important contribution to exploring and explaining identity

focuses on the extent to which identity should be understood as, and

through, narrative. Somers and Gibson suggest that theories of identity

should focus on the substantive nature of the narrative, and acknowledge

that ‘social life is storied’:

… people construct identities (however multiple and changing)

locating themselves or being located within a repertoire of

emplotted stories. (1994, p38)

27

Lawler, following Ricoeur (1991), highlights how ‘emplotment’ (that is, the

process by which a plot becomes a plot ‘through action or transformation

and characters’) is central to the understanding of ‘narratives’ (Lawler

2008, pp14-15). She suggests that [through this perspective]:

The self is understood as unfolding through episodes which both

express and constitute that self…So identity is not something

foundational and essential, but something produced through the

narratives people use to explain and understand their lives.

(Lawler 2008, pp16-17)

However, Somers and Gibson suggest that people act only within the

limited range of narratives available to them:

…people make sense of what is happening to them by attempting

to assemble or in some way integrate these happenings within one

or more narratives; and…are guided to act in certain ways, and

not others, on the basis of projections, expectations, and memories

derived from multiplicity but ultimately limited repertoire of

available social, public, and cultural narratives. (1994, pp38-39)

Lawler also warns that using narratives to explore identity can be

misleading, where people ‘borrow’ from the stories of others by not being

who or what they claim to be (often interpreted as ‘a breach of

fundamental social rules’) (2008, p30). I would suggest, however, that this

is a danger for all work on identities and not just those focusing on

narrative; the extent to which one accepts the ‘performance’ of the

‘identity’ presented must surely be an occupational hazard of those

studying identity, resulting in a need for a degree of critical reflection

during analysis. Additionally, it has been recognised that narratives are

representative only of the time at which they are gathered: they express

current views ‘rather than being actually representative of the future or

past’ (Beech and Sims 2007, p300). Nevertheless, as narratives ‘can

highlight the ways in which lived experiences and identities are embedded

in relationships’ (Lawler 2008, p30, emphasis added), interpreting

28

narratives is a particularly useful tool for a study exploring identities which

can only be achieved through membership of a group – an occupation

which is itself perceived to be a profession.

The theories examined so far have shown how the identity of an individual

may be described as one of multiple, simultaneous identities, how it may be

‘acted’ and ‘interpreted’, shaped by selves and others, and understood, at

least in part, through exploring the narratives which people use to explain

their lives. Nevertheless, another important feature of ‘professional

identity’ is the notion of a group identity – that is to say, while an individual

earns the right to call themselves a ‘professional’, they do so by becoming a

member of a profession, composed of a group of individuals who have also

earned the right to be viewed and described as professional. Wenger

(1998) suggests that professional identity is mutually constituted between

individuals and groups, and develops through the learning by participation

in practice, while Kalet et al. (2002) propose that the key to developing a

meaningful understanding of professional values and skills is the

purposeful mentorship of students. These proposals relate to the view that

one of the significant factors in professional identity development is how

students are socialised into their profession – that is, how they are

influenced by those with whom they come into contact and who share the

same or similar identities: peers and tutors, practicing members of their

profession and members of other professions. It is possible to see how the

notions of ‘performance’ proposed by Goffman are particularly relevant to

the process of socialisation, which can be described as a process of making

a professional identity ‘believable’:

…the highly socialized member of a profession so plays his role

that they appear inseparable from him…The development of a

professional self-conception involves a complicated chain of

perceptions, skills, values, and interactions. In this process, a

professional identity is forged which is believable both to the

individual and to others. (Lortie 1966, p98, emphasis added)

29

‘Socialisation’ is a concept that can be applied to all H&SC professions (see

Adams et al. 2006) and has implications for IPE and collaborative practice

because of the way in which negative experiences of, or negative

discussions about, working with other professionals may reinforce

undesirable behaviour towards - or stereotypes of - other professions. The

implications are that there is a need for all practicing health and social care

staff (including academic staff) to be good role models, regardless of

whether IPE is delivered formally or not, to ensure that students are not

exposed to negative attitudes or behaviour towards other professionals or

to the concept of IPE. The topic of ‘role-modelling’ has itself been widely

discussed in medical education literature, and is considered to be part of

‘the hidden curriculum’ (Pollard 2008). The process by which individuals

absorb and acquire information in both formal learning settings but also in

less-conscious ways through observation and non-formal learning has been

noted to occur regardless or not of whether behaviours are desirable

(Cheetham and Chivers 2005). Thus while the concept of socialisation is

important to the understanding of the forming of professional identities, it

is also associated with the forming of opinions and attitudes towards other

professions and collaborative practice. Consequently this thesis aims to

explore how perceptions of professional identities might be influenced by

experiences of interprofessional education and working.

To a certain extent one could argue that a person does not choose to have a

‘professional identity’ and that, while for some it may become a welcome

part of their personal identity, for others it may be a necessary but

unwanted consequence of choosing a certain occupation. In health and

social care this might arise from or reflect a desire to not have people

revealing their health problems in social / recreational situations, but may

also be because of the expected standards of upholding a professional

identity and status, even while ‘off-duty’ and in personal spaces (such as

social media sites). Nevertheless, it must be acknowledged that a

professional identity indicates someone who upholds it as a member of a

30

group, and as a result, the ‘social identity theory’ (SIT) first developed by

Henri Tajfel in the 1970s (Hogg 2006) is of some relevance.

According to SIT, the self-concept is comprised of personal identity

encompassing idiosyncratic characteristics (e.g. bodily attributes,

abilities, psychological traits, interests) and a social identity

encompassing salient group classifications. Social identification,

therefore, is the perception of oneness with or belongingness to

some human aggregate. (Ashforth and Mael 2004, p125)

Tajfel suggested that social identity is, in part, about the emotional

significance of belonging to certain social groups (Hogg 2006).

Psychological studies based on SIT have implied that merely categorising

an individual as a member of a group by apportioning a label (for example,

being in ‘group x’) results in people discriminating in favour of their own

group (Ashforth and Mael 2004 based on Brewer 1979 and Tajfel 1982).

However, despite offering a way to interpret an identity arising from group

membership, this thesis will not use SIT to ‘universalise work identities’

(Mendelson 2011, p167). Indeed, a study by Machin et al. (2011) exploring

the role identities of health visitors notes that even where there are shared

reference points for identity such as a profession, ‘collective identity cannot

be assumed’ (p1532). While understanding the social aspect of identities

which arises through membership of a professional group is important for

the implications it may have - for organisations, for intergroup conflict and

for individuals, if they face conflicting demands - it is not my intention to

suggest that there is such a thing as a ‘universal work identity’ held by

those who share a profession, nor should the allusions to SIT here be

interpreted as such. Returning to Mead’s suggestion that the self is

something that arises out of social experience, I would reiterate that

identity needs to be seen as something that is personal and non-

generalisable, arising as it does from our own experiences and

interpretations of them. O’Connell Davidson was writing about

prostitution when she suggested that there is a:

31

[c]ontinuum in terms of earnings, working and conditions and the

degree of control that individuals exercise…the experience of those

at the top of the hierarchy is vastly different from, some would say

incomparable to, that of individuals of the lowest rungs.

(2005, p34)

I would suggest that this is an equally relevant description for most if not

all professions. I therefore propose that identity and professional identity

need to be viewed as uniquely personal; experienced by individuals

through the social nature of interactions both in and out of work. However,

where a ‘professional identity’ becomes meaningful for an individual, it is

possible to understand how anything interpreted as a ‘threat’ to this

identity could be interpreted as problematic; in particular, this could be

exacerbated where individuals or individuals who share an element of their

identity (and are therefore seen as a group) become defensive and / or

competitive over their distinctiveness, or their ‘consensual status and

prestige’ (Hogg 2006, p113). This negotiation over managing identity and

the way in which perceived variations in role may reflect role autonomy is

described by Machin et al. (2011) as being part of the Role Identity

Equilibrium Process (RIEP) (Figure 2.1). Drawing upon Collier (2001) and

Foley (2005), Machin et al. (2011) describe how personal identity roles are

stabilised through ‘self-referent, verifying feedback’, while also

acknowledging that identity is influenced by interactions over time in

professional practice settings. While Machin et al.’s (2011) model was

developed after a study involving just one profession (health visitors), it

helps to demonstrate the extremely complex nature of ‘maintaining’ an

identity for all professions, from just one interpretation of the many

influences upon it.

This section has examined how identity is understood by social theorists to

be constructed by both the self and other’s interpretations of it, so that

while each individual has their own unique identity, it cannot be defined as

one thing; identities change according to scenarios and audiences, and

individuals can have many, simultaneous ‘identities’. Using the concept of

32

Figure 2.1: Machin et al.’s (2011) Role identity equilibrium process

Source: Machin et al. 2011, p1530.

narrative as a tool is helpful in understanding identities, as it allows people

to explain who they feel they are and how they got to that point, for any

given moment. The concept of ‘professional identity’ has also been

explored, and how its portrayal by an individual identifies them as

belonging to an exclusive group. For H&SC staff, this leads to certain

responsibilities over how they are seen to act both in and outside of work

where they still represent their profession. This also raises questions for

how H&SC professionals gain their identities through the process of

socialisation, as they learn to ‘perform’ their roles in order to meet the

expectations of their peers, other professionals and patients / service-

users. The next section will examine in more detail the claims made about

33

the professional status and identity of various different health and social

care professions in order to understand where the differences between the

different professional identities come from.

2.4 The professional identities of the health and social care

professions

This study involves exploring the perspectives of a variety of different

H&SC professionals. While the history of some professions is summarised

(where pertinent), this section is not intended to provide a detailed history

of each profession (the entirety of each of which would be worthy of a

thesis in its own right). Rather, the main debates around professional

identity of the H&SC professions are explored in general, using as many

examples from different professions as is appropriate, with brief

descriptions of the history of various professions where relevant.

Additionally, this section is based on existing works concerning only some

of the sixteen H&SC professions involved in the ALPS CETL programme.1 A

number of these professions were not represented in the fieldwork (see

Chapter Four) and the discussion of different professional identities

presented is based upon those professions who represented the largest

proportion of respondents in the study (doctors, nurses, midwives,

physiotherapists, occupational therapists, social workers, audiologists, and

diagnostic radiographers). Attempts were also made to identify work

concerning the professional identity of dieticians and speech / language

therapists, but a series of searches revealed no suitable material.

2.41 The role of regulators and professional bodies

Before discussion of individual professional identities, it will be useful to

acknowledge the part that the regulatory bodies play with reference to

1 Audiology; Clinical Physiology; Dentistry; Diagnostic Radiography; Dietetics; Medicine; Midwifery; Nursing; Occupational Therapy; Operating Department Practice; Optometry; Pharmacy; Physiotherapy; Podiatry; Social Work; Speech and Language Therapy.

34

their influence on the roles (and subsequently identities) of professions

and professionals for which they are responsible. All H&SC professionals

are required to register with a professional (regulatory) body tasked with

ensuring that individuals adhere to required standards. These are different

from professional associations (such as the British Medical Association

(BMA) and the British Association of Social Workers (BASW)) which are

the trade unions of various professions but to whom individual

membership is voluntary. Regulators can establish rules, ensure

conformity with them and ‘manipulate sanctions…in an attempt to

influence future behaviour’ (Scott 2001, p52). The professional bodies for

H&SC are therefore expected to maintain an up-to-date register of

professionals; set and maintain standard for education, training and

conduct; and investigate when these standards are perceived not to be met

(HSE website). Professional bodies are both regulators and advocates of

the professions they represent.

As a result of being responsible for education, training and professional

standards, it could be argued that the professional bodies are the most

influential actors in defining what is considered ‘professional behaviour’

and, therefore to a certain extent, identity (although there may be gaps

between the two). As Hugman (1991) points out, through membership of

such bodies, there is a ‘tendency to create new power structures, which

enhance the position of professionals at the expense of others’ (p222). The

result is that professional bodies – in theory – hold much power over

individuals and subsequently the professions they represent, and can also

exert a powerful influence in policy making concerning H&SC services

through the ‘external pressure’ they are able to apply as a regulative

element (Currie and Suhomlinova 2006). However, it should also be noted

that while it is widely accepted that professional bodies are powerful, there

is little academic literature exploring the extent to which they currently are

powerful or how this power manifests itself.

35

Table 2.1 maps out the professional bodies and the professions they

represented in England in 2013. Of particular note is that social workers

are now registered by the Health and Care Professions Council (HCPC).

Table 2.1: Professional Bodies in England, 2013

Professional Body Responsible for

General Medical

Council (GMC)

Doctors

Nursing and Midwifery

Council (NMC)

Nurses; Midwives

Health and Care

Professions Council

(HCPC)

Arts therapists; Biomedical scientists; Chiropodists

/ Podiatrists; Clinical Scientists; Dieticians;

Hearing aid dispensers; Occupational therapists;

Operating department practitioners; Orthoptists;

Paramedics; Physiotherapists; Practitioner

psychologists; Prosthetists / Orthotists;

Radiographers; Social workers and Speech and

language therapists

General Dental Council

(GDC)

Dentists; Dental nurses; Dental technicians; Clinical

dental technicians; Dental hygienists; Dental

therapists; Orthodontic therapists

General Optical

Council (GOC)

Optometrists; Dispensing opticians; Student

opticians; Optical businesses

General Chiropractic

Council (GCC)

Chiropractors

General Osteopathic

Council (GOsC)

Osteopaths

General

Pharmaceutical

Council (GPhC)

Pharmacists; Pharmacy technicians; Pharmacy

premises

Source: HSE Website

This has only been the case since August 2012, with social workers

formerly registered with the (now defunct) General Social Care Council

(GSCC). The GSCC was abolished after a review by the Department of

36

Health (DH) into ‘arms-length bodies’ concluded that there was ‘no

compelling reason’ to retain it and suggested that there were ‘potentially

significant benefits’ from combining regulation of social workers with other

healthcare professions (Dunning 2010). The impact on the profession of

moving social work regulation to the HCPC, which has previously only had

a healthcare as opposed to a social care focus, is as yet unknown.

2.42 All professions are equal, but some are more equal than others?

When talking about professions in general, Greenwood wrote that

occupations in a society should be considered along a ‘continuum’ (1957,

p510), which implies that some professions are more professional than

others. In discussing the professional identity of those employed in H&SC it

is tempting to conflate – misleadingly – the notion of a continuum of

professions with the traditional hierarchical nature of a healthcare team,

which has someone (often a doctor) at the top as decision maker and

ultimate team leader, forming a necessary organisational structure for

effective teamworking. Freidson (1970), for example, notes that the

hierarchy of institutional expertise renders medicine the dominant

profession in terms of the division of labour in health and social care. This

is also not to deny Abbott’s (1988) claim that there is a ‘system’ of

professions, which involves a ‘currency of competition’ in the form of

knowledge systems and their degree of abstraction, resulting in

interprofessional contestation and the potential for subordination of some

occupational groups by others. However, for a ‘continuum’ to be relevant,

with some occupations deemed ‘more professional’ than others, each

occupation would have to be judged on the same set of criteria, such as

those defined by the ‘trait approach’ to defining professions. But, as

already discussed, such an approach, while useful for identifying general

characteristics associated with professions, is not considered particularly

helpful because it assumes there exists an ‘ideal type’ of profession (often

characterised by medicine or law). This is evidently not the case, with

consideration given to the different functions of different roles carried out

37

by different professions, so that instead of a continuum, one could make the

case that they are ‘differently professional’. In other words, where

occupations demonstrate a unique body of knowledge, and consequently,

role which requires the fulfilment of tasks in complex situations to help

others (a ‘professional task’ as defined by Eve and Hodgkin 1997), the

attribution of the label ‘profession’ can easily be argued to be applicable

without objection. However, as each profession performs different roles,

the extent to which they have certain traits will necessarily differ, and it

therefore seems incongruous to suggest that one could rate one profession

as being ‘more professional’ than another. Rather, each profession can be

seen to perform the professional role as specific to their profession, and, as

such, each profession could be said to be ‘differently professional’ to

another. The rest of this section will therefore examine how the

professional status and identity of a variety of H&SC occupations has been

described, but will not claim that one profession is ‘more professional’ than

others, as this thesis’s argues that such a conceptualisation is inaccurate.

2.43 Medicine

Doctors have often been used as a paradigmatic example of a profession,

and as such there is little debate as to their right to claim professional

status. Eve and Hodgkin (1997) suggest that medicine has always occupied

a ‘singular and interesting position amongst the professions’ because it is

the only one of the ‘traditional “learned professions”’ that is based on

science and technology (p69).

In Britain, the medical profession was officially founded via royal charter in

the early sixteenth century (Macdonald 1995). The publication of medical

registers in 1779 has been argued to be:

[a]n important step in the professionalization of medicine…

enabling patients to choose practitioners and practitioners to

contact each other. (Lane 2001, p15)

38

Whilst regulation of the profession came later in the form of the 1815

Apothecaries Act, the state left the initiative to unify the profession, and to

set up regulative mechanisms, to reformers and the professionals

themselves (Macdonald 1995, p77 emphasis added). Thus, a great deal of

theory and research on the medical profession has focused on the power

and influence of doctors, over both their own profession (including

education) and other paramedical occupations (Macdonald 1995; Larkin

1983; Wilding 1982). The introduction of the National Health Service

(NHS) in 1948 changed medicine from a consumer product to a state

service, with Lane suggesting that:

…changes within medicine itself, bringing enhanced status and

prosperity to practitioners, in turn gave consultants and GPs a

place in society by the twentieth century that their predecessors

could not have envisaged, except for the few grand physicians and

‘surgeon princes’ of earlier periods. (2001, p202)

Eve and Hodgkin (1997, p72), however, suggest that within the healthcare

system at least, the status of doctors had been ‘downgraded’ since the

1950s and 1960s, when they had much more influence on the services and

policy developments that guided the NHS than they did by 1997, when an

erosion of some ‘power’, brought about by increases in accountability to

the government, professional bodies and patients had occurred (p76).

Whilst this is not necessarily a bad thing from the perspective of patients, it

still says little about the actual role and identity of doctors in the modern

era. Eve and Hodgkin suggest that (to 1997) ‘the role and form of

professional education has changed little for practising doctors’ (1997,

p77), resulting in professionals who had no means of keeping up with an

exponentially growing knowledge base. The recognition of the need for

this to change, and the need to focus on the responsibilities of holding the

role of doctor led to a large amount of attention being paid to the teaching

of medical ‘professionalism’ (Goldie et al. 2007; Hilton and Slotnick 2005).

This included a recommendation in the 2003 version of Tomorrow’s

Doctors that ‘professionalism be included as a curricular theme in

39

undergraduate medical education’ (Goldie et al. 2007, p610). However,

there is little consensus on the most effective methods to either teach or

assess professionalism (one review, Lynch et al. 2009, suggested that at

least 88 different assessments of professionalism have been used in

medical education since 1982). Noted tensions exist within medical

education between the discourses of ‘diversity’ and ‘standardisation’,

where diversity emphasises respect for individual students and life

experiences, and standardisation concerns ‘uniformity and consistency’

and a drive to define what is ‘core or essential’ to being a physician (Frost

and Regehr 2012, p2). Student doctors are thus expected to embrace both,

with the consequence of this being that medical educators are concerned

that students’ professional identities do not align with expectations. In

order to ensure that the transformative process of student to doctor is not

complicated by these competing discourses, this tension must be

recognised and acknowledged for future generations of physicians (Frost

and Regehr 2012).

Hilton and Slotnick (2005) suggest that in medicine, identity develops

during learning that takes place before ‘mature professionalism’ is reached,

an extended phase which occurs over years of medical training which the

authors refer to as ‘proto-professionalism’. They propose that ‘the

professional’s development of identity is a product of two simultaneous

processes: attainment and attrition (Hilton and Slotnick 2005, p62). The

process of attainment they describe as being about ‘positive influences’ that

include curriculum design and clinical environment. Applying Lave and

Wenger’s concept of ‘legitimate peripheral participation’, they describe

how medical students start at the periphery of activity of the profession,

mimicking practicing clinicians (performing physical examinations, for

example) but without treating patients; then, as they mature and learn

more skills, they eventually find themselves at the ‘centre’ as independent

clinicians (Hilton and Slotnick 2005, pp62-63). Moving from the periphery

to the centre involves moving through different ‘identities’, as, at different

stages, how they relate to others and their role will differ, and while these

40

experiences and opportunities in themselves do not constitute

professionalism, ‘they are necessary for professionalism in the future’

(Hilton and Slotnick 2005, p63).

In contrast, Hilton and Slotnick draw attention to the role of attrition,

which highlights that identity formation does not always occur as a result

of positive encounters and experiences. Attrition results from adverse

effects of the environment including ‘negative role models, unsupportive

work conditions and pressures of overwork’ (Hilton and Slotnick 2005,

p63). Similarly, work by Kilminster et al. (2010) on ‘transitions’ of

qualified medics (where a ‘transition’ is defined as a change in seniority,

geographical location, specialty or clinical team) shows how the

performance of doctors, their practice and their learning are ‘mutually

constitutive’; however, the performance levels of doctors does not:

…increase incrementally across transitions or even remain stable

within each transition… (p566)

as performance was seen to rely upon a multitude of demands placed on

doctors, and factors including but not limited to ‘time, specialty, hospital

rotas and trust policies’ (p566).

These works provide particularly significant context for this thesis, as they

recognise that professional identity arising from professionalism and

performance for medics arises from both long-term experiences, and

reflections upon those experiences. Recognition is also given to the fact

that the culture of the workplace is extremely important to understanding

effective performance (and therefore role). Hilton and Slotnick conclude

that the consequence of their findings for those yet to qualify is a need to

‘provide stage-appropriate experiences’, maximise ‘opportunities for

attainment’ and minimise ‘inappropriate attrition’ (2005, p63), although

these are equally applicable recommendations to assist qualified staff. For

this to be achieved, consideration must be given to how doctors learn from

peers and role-models through socialisation into their profession.

41

Much of the discourse surrounding the professional identity of doctors

considers the process by which they ‘become’ doctors and are socialised in

to the world of medicine. Indeed, some recent literature on the professional

identity of doctors focuses on how those who train in medicine identify

with the role of a doctor – both before and after studying - to become one

(see Pratt et al. 2006 and Gude et al. 2005). Such studies are not new.

Becker et al.’s (1961) highly influential study Boys in White followed and

described the process of ‘becoming’ a doctor in great detail after studying

students from every year group at the University of Kansas Medical School

in 1956-57. Whilst they do not talk about the concept of ‘socialisation’

explicitly, they discuss how students entering medical school are idealistic

about the way in which they will practice medicine in a patient-oriented

way, but ultimately they act as all other medical students do and often just

do what they ‘have to’, in accordance with expectations and pressures upon

them. Hilton and Slotnick (2005, p63) describe this as part of the ‘attrition’

process, where self-interest or self-preservation ‘takes precedence over

altruism’. Similarly, Becker et al. (1961) examine the way in which the

medical students end up focusing on ‘what the faculty wants’ from them

(which enables them to gain both clinical experience and more

responsibility). More recently, Apker and Eggly (2004) have discussed the

way in which formal teaching on wards through a morning report

socialises the medical residents (in the US) into the accepted way of

thinking about patient cases – i.e. about the medical issues involved and not

about the more personal and humanistic characteristics of students.

Hamstra et al. (2007) also examine socialisation into medicine, and

propose that in the past residents worked long hours in order to impress

their supervising doctors ‘and in the process develop their professional

identity’ (p8) (although the article assumes that this occurs, it does not

explore this process in any detail).

One of the difficulties of ensuring that socialisation into one’s own

profession is a positive experience is that all professions can be described

by a series of pre-conceptions and stereotypes. We all ‘know’ what a

42

doctor is and therefore their identity should be obvious to us; and those

who become doctors should know how to identify themselves as such (in

line with Goffman’s theories on performances and role management).

Nevertheless, very little of the preceding discussion on ‘identity’ described

the actual role of doctors. The primary reason is illustrated by Eve and

Hodgkin who highlight that the huge variations in the practice of medicine

can lead to individual patients with identical conditions being treated in

‘radically different ways by highly qualified professionals’, whose corpus of

knowledge is (theoretically) the same, but where importance is given to

‘clinical freedom’ (1997, p71). Thus there is no ‘single professional

identity’ that describes a doctor, nor indeed any other profession. As we

have seen, there are merely ways to make claims to ‘professionalism’, a

process that will now be explored and discussed with reference to other

professions from health and social care.

2.44 Nursing

Nursing has not traditionally been afforded the same status as medicine

and has been described variously as a ‘semi-profession’ (Etzioni 1969), a

‘personal service profession’ (Halmos 1973), and a ‘caring profession’

(Abbott and Wallace 1998). Until the 1860s:

...nursing was regarded as a superior form of domestic service

relying mainly on respectable working class women…these women

would have no background or identity as nurses and the

supervision of nursing care was a marginal part of their work.

(Dingwall et al. 1988, p69)

It has been claimed that the transformation of nursing into a ‘career’ for

young middle-class women was led by reforms introduced by Florence

Nightingale, although feminist historians have suggested that the purpose

of mobilising the Nightingale ‘myth’ was to ‘serve colonial and nationalistic

aspirations’ (Hallam 2000, p10). However, when new ways of practicing

medicine were developed in the 1830s, it was recognised that there was a

43

need for a new role: ‘a new type of assistant who could monitor the

patients’ (Abbott and Wallace 1998, p41). Nightingale recognised the need

to develop nursing into an occupation, and the need for training, yet

initially training was provided only in ‘obedience’ to ensure that nurses

realised they were subordinate to doctors, with emphasis given to the

notion that nursing was a vocation rather than a profession (Abbott and

Wallace 1998). For those professions typically understood to be ‘female

professional projects’ (Macdonald 1995, p133), (including health visiting,

midwifery and social work) it has been suggested that:

…the conditions under which these female occupations were

allowed to develop meant that women entered the public sphere

on terms defined by men and exchanged private patriarchy for

public patriarchy. (Walby 1990 in Abbott & Wallace 1998, p48)

Thus the history of the nursing profession and the identity of nurses have

long been associated with a female identity, in opposition to, and

undermining of, the power held by medical men (Hallam 2000; Poovey

1989).

Additionally, the treatment of nurses as a ‘disposable workforce’, because

they are seen as ‘young, female and easily replaced’, also needs to be

considered (Mackay 1998, p59). In England, one could substantiate this by

looking at the ever-changing nature of the health care system, which, based

upon the funding restraints and organisational models imposed by

successive governments, mean that the publically funded H&SC system is

an uncertain place to work. Whilst doctors also work in the same system,

nurses have historically taken less time to train, which does seem to

substantiate at least some of the argument that nurses may be seen or

treated as more ‘disposable’ and therefore the system in which they work

is more uncertain and unstable. (Nevertheless, from September 2013, all

new entrants to the nursing profession will have to study for a degree,

which itself may have some implications for the nursing ‘identity’.)

44

In 1969, Etzioni suggested that nursing (amongst other roles) should not

be considered a ‘true’ profession because they have less of a specialised

body of knowledge, less autonomy and control and less training in

comparison with what he defines as the professions. But this implies that

all professions can be defined by the same set of traits, a notion that is

argued in this chapter to be misleading. This history of having claims to

their professional status questioned has (perhaps unsurprisingly) led to a

situation where nurses are quite often perceived to be defensive about

their professional status, and consequently the identity that accompanies it

(Hallam 2000; Tschudin 1999); indeed some explorations of the nursing

profession focus purely on a ‘loss’ or ‘crisis’ of identity. Deppoliti (2008),

for example, suggests that in part, loss of identity for nurses in the United

States relates to how financial reimbursement for nurses connects to

decreases in patient stay, and that nurses – who gain some of their

identities from positive feedback from patients – are in danger of losing

this, as they no longer have the opportunity to get to know their patients in

any depth (p261). In the UK, the ‘identity crisis’ in nursing has also been

associated with one of the biggest reforms to nursing and nursing

education in recent history: Project 2000.

Introduced in the late 1990s, Project 2000 moved responsibility for nurse

education away from hospitals and into Universities and higher education

establishments. Where previously some diploma and degree courses had

been available, Project 2000 made such a route into nursing compulsory,

and phased out apprenticeships where nurses were attached to hospital

schools or trained ‘on the job’. The overarching aim of Project 2000 was to

enhance educational standards, the key to which was seen as being

achieved through the introduction of supernumerary status for students

(that is, being seen as additional members of a clinical team who learn on

placement rather than being paid members of the team who ‘learn on the

job’) (Elkan and Robinson 2000). Meerabeau suggests that one of the key

themes in work on the socialisation of nurses pre-Project 2000 focused on

a ‘theory-practice gap’, which indicated a disjuncture between what was

45

taught and what was practised on wards (and specifically that ‘care on the

wards was routinized and not patient-centered’) (1998, p83). However,

discussion of these issues is still evident post-Project 2000 implementation,

and, of interest to this project, is linked with concerns over the identity of

the profession. Indeed, it is noticeable that concerns raised about the

socialisation processes of nurses are similar to the issues raised relating to

doctors. A number of small-scale studies identify transition points through

different stages of learning as key points of uncertainty, necessitating the

adjustment of expectations about role (Gray and Smith 1999; Maben and

Macleod Clark 1998; O’Neill et al. 1993). Similar to Hilton and Slotnick’s

research, Gray and Smith conclude that the key factors in the socialisation

of nurses are ‘the mentor and the learning environment’ (1999, p646),

although they acknowledge that one of the limitations of their study was

that it followed students only through the common foundation unit of their

programme (that is, before they began training in the specific branch of

nursing in which they were going to qualify). Freshwater (2000) also

raised concerns over whether the teachers of nurses (who in the UK are

nurses themselves) feel able to use their own positions of power, and

subsequently questioned whether nurses have been socialised ‘into having

no voice by the teachers who may themselves feel oppressed’ (p484). She

proposed that the current system of nurse education (which nurses argued

should be nurse-led) was in ‘danger of reinforcing the submissive position

of nurses’ (Freshwater 2000, p484).

Scholes (2008) also provides a brief editorial on the ‘identity crisis’ in

nursing, suggesting it is caused by the challenges found in the

contemporary healthcare context, which implies that the theory of nursing

does not match up to the realities of clinical practice. However, one could

question whether nursing is alone in facing such a ‘crisis’. As previously

discussed, the situation in which the medical undergraduates found

themselves in Becker et al.’s (1961) study was not all that they had hoped it

would be when the realities of working in a pressurised health care

environment became apparent; nevertheless, education and training have

46

obviously moved on considerably since this study was undertaken in the

1950s.

In addition to concerns raised over whether nurses are being socialised

appropriately to prepare them for their role, and work with other

professionals, Abbott and Meerabeau (1998) highlight that some critics

still suggest that the work of the caring professionals (including nursing,

health visiting, midwifery and social work) is not specialised enough to

require training, and that instead it should be seen as an extension of work

that women are expected to carry out ‘naturally’ in the domestic sphere.

This demonstrates Abbott and Wallace’s suggestion that ‘gender ideologies

are an important factor in all the caring professions’ (1998, p47). The fact

that ‘care’ is seen as an extension of female role means that all those

occupations focused around its provision are afforded a less privileged

status. It has also been argued that providing such ‘care’ is a form of

‘emotional labour’ (Hochschild 1979; 1983) which itself requires complex

emotion management, and that as a role it can be as challenging and

productive as physical and technical work (Bolton 2000). Furthermore,

some propose that it would be dangerous for nursing to lose its focus on

authentic caring behaviour by over-emphasizing a need to develop

technical skill (Bolton 2000; Downe 1990) and that ‘something intrinsic to

nursing practice would be lost if the vocational element were extinguished’

(Mackay 1998, p69).

The claim of a ‘professional identity’ in nursing is therefore complicated

because, historically, notions of ‘caring’ and ‘professional’ have been

interpreted as contradictory. As medicine has previously been treated as

the ‘ideal type’ of profession, the desire to combine ‘caring’ and

‘professional’ has consequently been interpreted as a dilemma for nursing.

Simultaneously, the key element that arguably defines the nursing

profession – the notion of ‘caring’, that makes it ‘differently professional’ to

medicine - has been used to critique and detract from its status, rather than

be seen as a defining professional feature.

47

Whilst there has been a relative paucity of later work concerning the

professional identity of nurses, one recent piece of research published in

Portugal suggests that nurses in one hospital still feel that, while they have

a recognisable identity, they also realise that their work still lacks socio-

professional recognition, which hinders relationships and effectiveness of

multi-disciplinary teams (Franco and Tavares 2013, p118). Whether there

is indeed a lack of recognition of status, or merely a perception by nurses

that this is the case (perhaps from being socialised into a profession which

believes it has such identity concerns), the implication is that while the role

and education of nurses has greatly developed and changed over the last

century and a half, some of the concerns around the identity and status of

the profession of nursing have moved on very little during this time.

2.45 Midwifery

Kirkham (1998) suggests that ‘midwifery has clearly aimed to be a

profession since the foundation of the Midwives Institute gave midwifery a

leadership voice’ (p123). Much like nursing, before the early nineteenth

century midwifery was practised by a variety of people (both men and

women), although only very few would have been ‘full-time practitioners’

(Dingwall et al. 1988, p153). However, unlike nursing, and despite initial

public opposition, it was male midwifery that started to dominate; by the

late nineteenth century, medical doctors agreed that ‘midwifery should be

undertaken and controlled by men’ such that by 1866 proficiency in

midwifery was ‘necessary for qualification as a medical practitioner’

(Abbott and Wallace 1998, p46). However, a distinction remained between

‘assistance at childbirth and intervention at childbirth’ (Abbott and Wallace

1998, p47), and while men controlled both the intervention side (only men

were allowed to use forceps and intervene surgically) and registration /

education (through the Midwifery Registration Act of 1902), women

midwives remained in control of the ‘assistance’ side (although Abbott and

Wallace (1998) suggest that this is only because there was no way in which

the trained male practitioners would be able to meet the demand for

48

assistance). This ‘deskilling and deprofessionalisation’ of midwives is

argued by Abbott and Wallace to have continued into the late twentieth

century where the ultimate control of births remained ‘in the hands of the

(generally male) obstetrician’ (1998, p47).

Recent studies have found that midwives in the UK perceive themselves to

have an inconsistent professional identity (Pollard 2011; Porter et al. 2007)

and that in Sweden midwives encounter challenges to their identity from

technology, other professionals and parents who make high demands of

them (Larsson et al. 2009). Both Larsson et al. 2009 and Pollard 2011

noted that there are still challenges for midwives in juggling midwifery

perspectives with medical perspectives on childbirth, which have

implications for power relationships, hierarchies and for notions of

professionalism. Pollard suggested that, in the UK, it was not surprising

that midwives held inconsistent positions and practices:

…given that the UK midwifery system demands that midwives

simultaneously adhere to a medicalised approach to childbirth, act

as advocates for women, practice according to the midwifery

approach, promote the professionalization of midwifery and

observe their contractual obligations as employees. (2011, p618)

To claim that they are an autonomous profession, it is suggested that

midwives need not only to be able to challenge medical supervision of their

work, but also to establish that their work is distinct from medical work,

with a unique knowledge and practice (Abbott and Wallace 1998).

However, this argument once again privileges the notion that traits

consisting of technical skill and unique knowledge would result in the

definition of midwifery as ‘more’ professional. This does not acknowledge

the professionalism that is demonstrated in the already unique skill and

role undertaken by the midwives during pregnancy and birth. The

discussion of professions in history has thus done little for the construction

of perceptions of some occupations as professionals, even when they are

carrying out unique roles in a professional way. For midwifery, this has led

49

to confusion not only about whether it is seen as a ‘profession’ by others,

but has also resulted in questions about the ‘professional identity’ of

midwifery by midwives themselves.

2.46 Physiotherapy

The history of physiotherapy is linked to the employment of Swedish

remedial gymnasts in the 1880s by ‘progressive members of the medical

profession for “medical rubbing” ’ (Jones 1991, p12; Wickstead 1948). As a

result, many women in Britain started undertaking this work as an

alternative or an addition to nursing and midwifery, with the setting up of

the Society of Trained Masseuses in 1894, which in turn led to medical

recognition of the role (through medical assistance in qualifying students,

and certificates of competence presented to those who reached a

satisfactory standard) (Jones 1991). By 1905, male nursing orderlies from

the Royal Medical Corps were allowed to take the examinations but were

not permitted to be members of the Society (by that time the Incorporated

Society of Trained Masseuses) as this included a right to membership of the

Trained Nurses Club, which did not permit male members (Jones 1991).

The development of physiotherapy as a profession is seen as having

increased with the skills of orthopaedic surgeons during the 1914–1918

war, with large numbers of patients surviving disabling injuries and the

surgeons needing assistance with the rehabilitation work (Jones 1991). In

1920, the need for the role was symbolically recognised with the granting

of a Royal Charter, but it was the founding of the NHS in 1948 that enabled

the Chartered Society of Physiotherapy (as it had been called since 1942)

‘to become the dominant occupational group in the remedial therapy

services’ (Jones 1991, p14). Nevertheless, the profession remained under

the control of doctors for many years, to the extent that the profession’s

ethical code stated that patients could only be treated after direct referral

from a doctor (Jones 1991).

50

The move towards an advanced level of clinical autonomy has been argued

to be the most significant change in the profession in the last 50 years

(Robertson et al. 2003), with Jones suggesting that this autonomy has

moved physiotherapists further along the ‘professional continuum’ than

nursing, because nurses’ work is still much more dependent on doctors

(1991, p16). The extent to which interprofessional comparison exists can

be seen in the way in which literature simply outlining the formation of one

profession is pervaded by such comparisons and positioning.

While some recent literature on the professional identity of

physiotherapists has focused on the role overlap between physiotherapy

and occupational therapy (Booth and Hewitson 2002; Brown and

Greenwood 1999) (whilst maintaining that the roles are indeed similar but

separate), a study undertaken between Sweden and the UK suggested that

there is a ‘diversity of professional identities in graduating

physiotherapists’ (Lindquist et al. 2006, p270). The authors identify three

distinct identities: ‘Empowerers, Educators or Treaters’; however, they

classified some of their participants in two of the three categories

(Lindquist et al. 2001, p274) (although it should be noted that this work

was conducted with students about to graduate and as such it could be

suggested that these may not be the identities of physiotherapists once

they are working and have lost their ‘student’ identity). Nevertheless, there

are still implications for educators and the socialisation process, including

the necessity of educators being aware of the ‘range of professional

identities that students may develop and the processes through which that

may occur’ (Lindquist et al. 2006, p275) to ensure that students are not too

far grounded in one philosophy to the detriment of others.

2.47 Occupational Therapy

Occupational therapy emerged in the years before the Second World War,

developing not to exploit new technologies, but as a therapy that was

promising once ‘it became possible to save the lives of those who would in

51

earlier times have died’ (Blom-Cooper 1990, p13). The origins of

occupational therapy came from a group of psychiatrists who, challenging

traditional medical treatments, ‘advocated a link between occupation and

health as a treatment or therapy’ (Clouston and Whitcombe 2008, p315).

While originally carried out by nurses under medical direction, the specific

role of ‘occupational therapy’ has emerged over time, although notably in

the (relatively small) body of work concerning occupational therapy and its

history, a lot is made of the ‘successive identity crises in name, focus and

purpose’ (Clouston and Whitcombe 2008, p315; Wilcock 2002) and the

‘struggle to establish [itself as] a self-governing profession with control

over recruitment and education’ (Blom-Cooper 1990, p18).

Occupational Therapy appears to be seen from both inside and outside of

the profession as one that struggles with its own professional status and

identity. In 1990, Blom-Cooper suggested that there were multiple reasons

for this:

the dominant position of medics in the health service and social

workers in care services;

the dependence of occupational therapists on doctors and social

workers for access to clients;

a stereotypical view of occupational therapists as ‘do-gooders’;

the female composition of the profession;

the difficulties of providing outcome measures of the efficacy of the

profession. (pp18-20)

In comparing occupational therapy to other health care professions, Blom-

Cooper suggests that occupational therapists are seen as performing

‘unskilled and common-sense tasks’, which do not earn the same respect or

prestige of the doctors whose skills come from ‘high intelligence and long

training’ (1990, pp19–20). He notably continues:

Even nursing, which is popularly regarded as requiring angelic

dedication in carrying out distasteful work, is given an enhanced

status. (Blom-Cooper 1990, p20, emphasis added)

52

Since Blom-Cooper’s report was published, there has been a paucity of

empirical research on the impact of changes to the health and social care

systems on the role and identity of occupational therapy (Clouston and

Whitcombe 2008), although Thompson and Ryan published a small scale

study involving looking at the influence of 600 hours of ‘fieldwork’

(placement experience) on four occupational therapy students in Canada in

1996. Their findings suggested that: there was a process of professional

socialisation by ‘osmosis’, and that while interactions between student and

therapist focused on the ‘technicalities of therapeutic interventions’, the

underlying beliefs and values of the profession were not explicitly

addressed, with students expected to absorb these ‘unconsciously and

interpret without questioning’ (Thompson and Ryan 1996, p69). However

this brings into question the extent to which it would be possible to ‘teach’

the ‘underlying beliefs and values’ of the profession, as well whether this

would be wholly expected to occur in a placement setting.

Finally, Thompson and Ryan note that:

The students in this study were aware of their natural lowly

position as neophyte professionals, but this position was

compounded by their awareness of the low profile of the

profession and its apparent invisibility. (1996, p69)

This was exacerbated, the authors claim, by the necessity for the students

to deal with the traditional ‘embedded hierarchy’ of healthcare where

doctors are the ‘key-decision makers’ (Thompson and Ryan 1996, p69).

While it might be argued that interprofessional education may be useful for

exploring these issues with students (a claim explored in Chapter Three), it

also brings into question the extent to which socialisation into a profession

involving being told (or having it reinforced) that this profession has a

weak – or strong – professional identity becomes a self-fulfilling prophecy.

The notion / mantra of ‘we are a weak profession’ (and which could be as

equally problematic as ‘we are a strong profession’) appears to be learned

53

and performed by the next generation of professionals, but this does not

appear to have been identified as potentially problematic in this case.

2.48 Social Work

While The Charity Organisation Society was credited with having

developed the ‘social work method of individualized casework’, social

work, like health visiting, was seen to provide not just a role but a career

opportunity for middle class women in the nineteenth century, after

developing out of a variety of voluntary, charitable and philanthropic

Victorian projects (Abbott and Wallace 1998, pp31-32). However, the role

and definition of social work’s boundaries have long been debated.

Gibelman identifies that as far back as 1915, the question of whether social

work was a profession was being raised by Flexner, and that later, in 1917,

Richmond sought to ‘identify the skill base for work with individuals and

families’ (Gibelman 1999, p299). Hugman (1991, p88) highlights that in

the UK, until 1970, there was little attempt made to campaign for a ‘unified

professional body’ in social work. As there was no single body to advocate

for social work as a single profession, this could explain some of the lack of

definition over identity. However, Gibelman argues that, despite variations

in the depth and scope, and being developed at different times, there is a

‘remarkable consistency’ to the definitions ascribed to social work over the

years (1999, p299). Horner reflects that one of the key questions relating

to social workers is whether all societies need them:

We take it for granted, perhaps erroneously, that other professions

– teachers, doctors, architects, lawyers – are social necessities, yet

concede that social workers are not automatic members of the list.

(2009, p14)

The answer to this question, Horner argues, lies in the extent to which one

believes it is the responsibility of the state to respond and intervene on

behalf of vulnerable and dependent people (2009, p15). It is not the place

of this thesis to debate whether there is a ‘need’ for social work, nor to

54

interpret the hugely complex and vast debate on the ‘sanction’ for its

existence, but the existence of the question is significant for this discussion,

as it places the role and identity of social workers in a different position

from that of the other health professions explored so far (for instance,

there is no long-running debate about the need for doctors, nurses,

midwives, physiotherapists or occupational therapists). Additionally,

Abbott and Wallace (1998) highlight how successive scandals relating to

child protection have resulted in social workers being ‘vilified’ in the press,

leading to a ‘further crisis of confidence for a fragile profession’ which led

some to challenge the ‘whole basis of social work’s professional practice’

(p38). This is a theme which can be seen to have culminated in the ‘hostile

reactions to social workers following the conviction of the killers of Baby P

in November 2008’ (Warner 2013). The ability of social workers to fulfil

their role of moral regulators is often questioned by the media on the basis

of real or imagined class-divides between the social workers and their

clients. Both Warner (2013) and Clapton et al. (2013) apply the lens of

‘moral panic’ to describe the reaction of the press to social worker

engagement in child protection cases, noting that social workers are

usually portrayed as the ‘folk devils’ (see Cohen 1972).

It is also important to remember that social workers operate in a different

part of the health and social care system to many of the other professions

discussed in this thesis, and those who work in the public sector are mainly

employed by Local Authorities rather than the National Health Service.

(The Health and Social Care Act 2012 may have some impact on the way

that social care is commissioned, but the impacts of this are yet unknown;

Samuel 2013). In addition, social workers have unique legal powers that

allow them to intervene in the lives of others (by, for example,

‘safeguarding’ a child or vulnerable adult, by removing them from their

home). These interventions can often result in situations where decisions

are disliked by the public; being seen as interfering and over-bearing in

cases where they successfully safeguard someone by removing them from a

home environment, or as having failed the moral system if they do not

55

remove someone from potential harm and something detrimental

ultimately happens to them. Gibelman concludes that:

The potential failures [of the profession] lie not in what directions

we choose but in not having the debate and allowing our profession

to be defined by the forces and decisions of others.

(1999, p308, emphasis added)

Unlike occupational therapy and midwifery, who have concerns over their

professions’ identity and justify their professional status by contrasting

themselves to other health roles, social workers are more concerned with

justifying the existence of their profession at all, despite the fact that social

work clearly occupies a unique role within the H&SC system. The

subsequent impact of this insecurity is that there are concerns over the

directions in which others (policy makers and other professional groups)

wish to push social work.

2.49 The ‘younger’ professions and ‘assistants’

While only representing a small portion of available literature, and a small

number of professions, the preceding discussion indicates how the struggle

for professional status and role is a recurring theme across all H&SC

professions for a variety of different perceived reasons. The use of phrases

such as ‘the professions allied to medicine’ and then later ‘allied health

professionals’ which have been typically used to describe any H&SC

profession outside of medicine, dentistry and nursing can also be seen to

have contributed to difficulties for individual professions seeking to

develop and control their own identities.

The identities discussed here still probably only represent those of the

largest and more established professions, and inevitably there is more

research available on them. Whilst there are some discussions of

professional identity of ‘younger’ professions, there are far fewer empirical

studies (and studies, generally) available. Lubinski and Golper’s (2007)

56

chapter on audiology and speech pathology, for example, provides a

discussion of the history of these professions in America, and suggest that

‘a certain noble motivation pervades our professional identity’ (p3), but

this appears to be only their opinion and is not evidenced in any way.

Niemi and Paasivaara (2007) explored the professional identity of

radiographers by using a discourse analytical approach to explore the

content of professional journal articles. They conclude that radiographers

have a dual identity, the first based on a command of scientific-mechanic

technology and a technical working environment, and the second based on

the humanistic element of nursing work. However, Bolderston et al. (2010)

(who interviewed radiation therapists), and Ekmekci and Turley (2008),

suggest that the ‘caring’ element of the role is different for those who work

in radiation therapy from other ‘radiologic science disciplines’. This is due

to radiation therapists’ prolonged and or / repeated patient contact, and

because of an expectation of patients receiving radiation therapy that staff

would have time to listen, and be both caring and sympathetic. This implies

that there are slightly different identifying features and therefore identities

for staff carrying out different roles under the same professional label,

which is interesting but not surprising given the individual nature of

experiences that result in different perceptions of group boundaries.

There are also those occupations that are not considered to be

‘professional’ because they have developed to fulfil very specific,

individual-task based roles which are not easily defined into one

profession. Gibbs (2013), for example, notes that sonography encompasses

a ‘broad spectrum’ of functions, the skills of which are covered by a number

of different professional bodies. However, while sonographers have often

undergone ‘rigorous training’ to achieve competence, and regulation of

sonography practice has been recommended by the HCPC, because their

role duplicates skills held by other professions, they are yet to achieve

recognition as a profession in their own right, a situation which Gibbs

(2013) suggests is unlikely to change any time in the near future.

57

One final category to note is that of ‘auxiliaries / assistants’, ‘technicians’

and ‘support workers’, and in particular Health Care Assistants (HCAs) who

are non-registered care-givers but who often perceive themselves as

‘substituting’ for registered staff (Thornley 2001). The role of the HCA has

been much reviewed in literature, and particularly from the perspective of

registered nurses, where discussions focus on the impact of the changing

role of nurses resulting in HCAs being expected to carry out more ‘nursing

work’, and whether this is appropriate given the level of competence of the

(usually untrained) HCAs (Spilsbury and Meyer 2004; McKenna et al.

2004). The untrained, unregistered assistants who work only under the

direct supervision of qualified staff are perhaps the most easily identifiable

group who are not afforded a ‘professional identity’ and yet they are still

expected to display elements of ‘professionalism’ in their work and

physically identify themselves as staff by the wearing of uniforms. To

distinguish the ‘professional’ from the mere ‘staff-member’ in H&SC is

therefore arguably not as straightforward as it would first appear, and

particularly if the meanings of different uniforms are not apparent.

In addition to those whose claim to a ‘professional identity’ is less clear,

there are also those in job roles whose professional role boundaries blur or

cross over other more traditionally distinct roles. In particular, ‘nurse

consultants’ and ‘assistant physicians’ both perform elements or tasks

more typically undertaken by doctors such as making clinical decisions or

re-writing drug charts. The changing of existing professions and

emergence of new roles raises questions about a subsequent need to

reassess perceptions of identity to ensure they reflect the modern

profession (Gough 2001). However, this needs to be done without

‘dissolving’ existing identities, which can be seen as a threat and

demoralizing to all those concerned (Howkins 2002). One of the challenges

for nurse consultants and assistant physicians is that there is a lack of

progression opportunities within these roles. Based upon an earlier study

she completed, Ewens (2003) noted that while nurses were keen to

embrace new roles and the accompanying identities, the realities of the

58

workplace opportunities were that organisations were unsure what to do

with such practitioners, and that their opportunities to expand or innovate

within their new roles were limited, leading to those in these roles feeling

very frustrated and discontented. It is thus apparent that the creation of

roles which extend professional responsibilities has many implications for

healthcare organisations, who need to be able to support (and develop)

those who undertake the roles, and for individual professionals, who may

no longer feel part of, or be identified as, a member of a specific profession

(differentiated as they are from the rest of their colleagues through

additional responsibilities).

2.5 Uniforms and signifiers

The wearing of a uniform, or certain role-related clothing, is perhaps the

most obvious indication that one belongs to a certain group. However,

although uniforms play a key role in delineating occupational boundaries,

there has been comparatively little empirical analysis into their function

(Timmons and East 2011). In 2004, Douse et al. conducted a study which

found that while 56% (of 276) patients preferred doctors to wear white

coats for ease of identification and because it looked ‘more professional’,

only 24% (of 86) doctors preferred to wear them, with the primary reason

for not doing so being concern about risk of infection. In fact wearing white

coats was banned in 2007 precisely because of the infection risk they were

found to carry (BBC News Website 17.09.07).

The majority of other existing work into wearing uniforms in H&SC focuses

on nurses. Spragley and Francis (2006) suggest that nursing uniforms are

‘nonverbal conscious statements’ that indicate that those wearing them

have the ‘skills and knowledge to care for others’, a point which could be

argued to apply to any H&SC professional who wears a uniform. The same

could be said of Newton and Chaney’s (1996) assertion that wearing a

uniform does not automatically denote that a nurse is ‘good’ or acts

professionally. While Douse et al.’s study into white coats for doctors

59

highlighted the symbolic significance of uniforms for patients, both Hallam

(2000) and Pearson et al. (2001) talk about the significance of the wearing

of a uniform for nurses, for whom it is perceived to give confidence to carry

out their role. Furthermore, Pearson et al. 2001 suggest that the uniform

can be seen as part of the ‘performance’ of their role (and conversely, that

when it is removed, they are able to take up other roles). Timmons and

East (2011) also identify the significance of uniforms for staff, having

studied the introduction of a new uniform for all professional groups in one

UK hospital, where:

…the only signifier of professions that remained after the change

was a small epaulette in the traditional colour indicating

profession (royal blue for nurses, green for occupational therapists

and navy for physiotherapists). Symbols of rank were also

substantially reduced… (p1039)

The introduction of the new uniforms was seen as ‘an explicit managerial

attempt to reduce the importance of boundaries between (and within)

professional groups in hospital’ (Timmons and East 2011, p1047). The

study concludes that the generic uniforms did not promote a corporate

identity (which in itself may not be an identity people viewed positively),

and if anything may have exacerbated rather than reduced professional

‘tribalism’. Changing the uniform was perceived as ‘an assault on

professional boundaries’ and concerns were raised that it was not possible

to tell one profession from another, which in some cases was potentially

dangerous; for example, one physiotherapist gave an account of witnessing

an auxiliary nurse being shouted at to fetch a crash trolley, a task she was

clearly not permitted to do as it was outside of her role (Timmons and East

2011). Thus it can be seen that wearing uniforms is considered to be

significant by patients and H&SC professionals alike, and as one of the few

‘obvious’ signifiers of professional identity they also remain functionally

important.

60

Another signifier of interest is that of the stethoscope. A ‘tool of the trade’

rather than an item of uniform, the stethoscope has arguably been

traditionally associated with doctors; Coombs (1978) argued that

professional socialisation for doctors was about ‘playing the role’ complete

with the ‘props’ of white coat, stethoscope, clipboard and name badge

(p222). These symbols, it has previously been argued, differentiate both

professionals and student-professionals from lay people and other

professionals (Beagan 2001). However, the stethoscope is not the sole

domain of the doctor and has not been for quite some time. In a narrative

example given by Chan and Schwind (2006), reference is made to a nursing

student being given, alongside her uniform:

…a pair of nursing scissors and a stethoscope, each engraved with

my name. All these are to become part of my full uniform, my visible

identity. (p306)

Thus while there are ‘props’ (tools) and symbols that may have previously

been associated with certain professions, even the demarcations of these

can be seen to be blurring across professions, if not removed completely

(as in the case of the white coat). While there is little academic work

exploring the impact of this, the loss of ‘obvious’ signifiers may be a

contextual reason for professionals to feel more defensive over their

professional identity in terms of job-roles, when they are less-easily

identified as ‘distinct’ from other professionals by sight. This is merely one

suggested hypothesis however, and without further work exploring this

area it is not possible to say whether changes to uniforms and symbols of

professions have had any impact at all on either professional or patient’s

perceptions.

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2.6 Occupational ideology and the notion of vocation

Another, less obvious aspect that can be argued to be common to all H&SC

professions is the notion of work as a ‘vocation’. The concept of ‘vocation’

is ideological, and is commonly used with those who enter ministry or

religious orders (Mackay 1998) and often refers to the way in which people

feel an inclination or ‘a calling’ to undertake a certain type of work.

However, in discussions about the extent to which people feel ‘a calling’ to

join the occupation they have chosen to join, it is also often applied to those

who work in H&SC. Occupational ideologies not only inform the way

people behave at work (Fox 1971), they also present a view of occupations

to society at large, to the public as well as to members of the occupation

(Mackay 1998). Any number of (potentially conflicting) occupational

ideologies can inform thinking about a profession at any one time, and

there has been some debate, particularly within nursing, as to the extent to

which the concept of ‘vocation’ is in contrast to being seen as ‘a

professional’ (see Salvage 1985). Burrage and Torstendahl (1990, p123)

note, however, that ‘idealised professions’ are expected to achieve the

substantial formal training while staying ‘very close’ to vocational work.

While it is technically possible for those who work in H&SC to ignore the

concept of vocation (Burrage and Tostehdahl 1990), the existence of the

ideology in the public mind means it still remains an important potential

feature of a professional identity.

2.7 Health and social care professions in competition: Silos and

Tribalism

Historically, discussion of differences in professional identity and the

culture of working in H&SC have focused on the professions in competition,

where they have been variously described as working in ‘silos’, or as

‘tribalistic’ in nature.

To a certain extent, the history of the H&SC professions is viewed as a

history of competition and claim to the rights about certain roles or aspects

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of work (Abbott 1998, Macdonald 1995), with Abbott stating that ‘a

fundamental fact of professional life [is] interprofessional competition

(1988, p2). The concept of ‘silo working’ is often referred to as an

unproblematised given (see Curran and Sharpe 2007) implying that, to a

certain extent, it is something we are all aware occurs and understand why

it happens. Hall (2005) explores this issue in more depth, however,

suggesting that the struggle for each profession to define its own ‘identity,

values, sphere of practice and role in patient care’ has been the major

contributory factor in determining the way in which H&SC professions

have typically interacted:

This has led to each health care profession working within its own

silo to ensure its members (its professionals) have common

experiences, values, approaches to problem-solving and language

for professional tools. (2005, p190)

Thus, Hall proposes that the educational and socialisation processes

solidify each professional’s ‘unique world view’ (2005, p190) as each

trainee aspires to be seen as professional and learns and repeats the views

of professionals who train them. In a review similar to Hall’s, Beattie

(1995) describes the development of the H&SC professions as ‘tribalistic’,

as a result of the way in which they have evolved separately.

Dalley (1989) also uses the term ‘tribalistic’ to describe the division

between agencies providing health care, and those who provide social care.

However, in a study exploring the introduction of a new IT system to

enable cross-agency working, Baines et al. conclude that while differences

in professional cultures are often ‘invoked rhetorically as barriers to

change’, the more significant impact is actually in the different pressures

from everyday practice (2010, p29).

The ‘divide’ between health and social care could be the topic of a thesis in

itself, but is succinctly summarised by Lymbery, drawing upon the work of

Lewis (2001) and Salter (1998), who describes the hidden policy conflict

between health and social care agencies as an inevitable result of the needs

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of the service user falling between two agencies (Lymbery 2006, p1121).

Critically for this study, Lymbery (following Hudson 2002) goes on to

suggest that:

…inter-professional rivalries do affect the quality of collaborative

working that can be developed…[T]here are three critical areas in

which these rivalries are played out; professional identity and

territory; relative status and power of professions; [and the]different

patterns of discretion and accountability between professions.

(Lymbery 2006, p1121)

Thus tribalism in H&SC is proposed to occur when the boundaries of

groups with roles that are perceived to be distinct appear to be threatened

by the integration of different professional groups (Carlisle et al. 2004). In

1995, Nolan suggested that – at that point in time – the fact that

interprofessional working (collaborative practice) had often remained only

rhetoric was attributable to the protectionism over professional

boundaries.

The role of socialisation has also been noted to contribute substantially to

the ‘development of “tribal” attitudes’ (Carlisle et al. 2004, p548; Atkins

1998; Seabrook 1998). What we begin to understand here is the complex

and interrelated nature of professional history, culture and identity and the

influence of these on interprofessional working. It is apparent that it is not

possible to define the professional identities of H&SC professionals without

knowing about their relationships with other H&SC professions, while at

the same time, interprofessional relationships are potentially influenced

by, and can influence, concepts of professional identity and status.

To add another layer of complexity, a further point for consideration is the

extent to which ‘traditional’ organisational structures within H&SC are

already seen to be changing. Eve and Hodgkin suggest that there is a need

to recognise that large organisations such as the NHS are moving from

traditional hierarchical structures to webs: ‘multiple small units with many

horizontal as well as vertical relationships, rather than a single monolithic

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whole’ (1997, p82). This, they suggest, results in ‘less emphasis on

following orders from above [and] more on working out the appropriate

local response’ (Eve and Hodgkin 1997, p82). The resultant ‘boundary

blurring’ through changing roles such as the introduction of ‘nurse

consultants’ in the NHS in 1999, or even the perception of ‘boundary-

blurring’, causes concern where it is believed to erode roles of certain

professions, and therefore create (further) uncertainty in relation to

professional identity (Baxter & Brumfitt 2008; Williams & Sibbald 1999).

2.8 Academic Identity

This chapter has identified the importance of the socialisation processes in

developing professional identity. Monrouxe (2010) proposes that:

Medical education is as much about the development of a

professional identity as it is about knowledge learning. (p40)

The same point may be made for all H&SC professions. The implications of

this include the need to understand the development of identities and the

processes by which identities are achieved. This includes understanding

the positions and opinions of those undertaking the facilitation of identity

development, either as academic teachers or clinical teachers.

A separate body of work on the professional identity of academics does

exist (Malcolm and Zukas 2009; Beck and Young 2005; Becher and Trowler

2001) much of it focusing on the way that academics achieve or struggle to

achieve ‘academic identities’. Archer’s (2008) study of ‘younger academics’

for example, suggests that ‘becoming’ an academic is not a straightforward

or linear process, and can involve ‘instances of inauthenticity,

marginalisation and exclusion’ (p387), arising from issues of age, contract

status or perceptions of the achievement of ‘success’. However, there is

little specifically concerning the identity of academics who teach and work

in H&SC, who having already ‘achieved’ one professional identity in health

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and social care, may face similar challenges as they enter the world of

academia.

For academics who are also H&SC professionals (or who initially trained as

such), the extent to which they identify themselves as a professional or an

academic / teacher adds a further layer of complexity to issues

surrounding their professional identity. Meerabeau suggests that:

It is debatable whether the latter is a distinct occupation (that of

the ‘don’, to use rather antiquated language) or whether the

primary identity of the university lecturer, particularly in

vocational courses, derives from the discipline which they teach.

(1998, p83)

Thus the extent to which those who teach in educational establishments

consider themselves academics, teachers, or purely as members of the

profession in which they originally qualified is important when trying to

understand influences on the socialisation of H&SC students.

The extent to which practicing H&SC staff perceive themselves as ‘teachers’

is also of interest. Lake (2004) notes that there is a tendency for doctors

who teach to have had little training to do so, and to be told that they are

typically poor at supervision and teaching. In these circumstances, the

extent to which a teaching identity would therefore be viewed as positive

and desirable might also be questioned. Emphasis was therefore given to

the questions raised here about academic and teaching identities in the

empirical elements of this research. Practicing members of H&SC staff were

asked about the teaching elements of their roles to establish how this

contributed to their identity as a professional, and the academic staff were

specifically asked if they identified themselves in the role of ‘teacher’ rather

than as the profession in which they originally trained.

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2.9 Summary

This chapter has explored notions of identity, and has explained how

‘professional identity’ can and should be seen as one of many simultaneous

identities. While identity is undoubtedly unique to each person, a

‘professional identity’ also contains elements of the ‘social’ because of its

association with a group of similarly qualified people. We have seen that

identities are associated with ‘performance of a role’, and as such they can

be interpreted differently by different audiences. There is also scope to

understand identities by looking at the ‘narratives’ that people build about

who they are.

The histories of the professions presented here are very broad. Not only

have large and complex histories of the professions been explored briefly,

but there has been little or no acknowledgement that what has been

explored is each profession ‘as a whole’. However, there are many different

branches and specialties of most professions discussed, each of which have

their own nuanced history and potential identity. Whilst this is not a theme

of the literature (although it emerges briefly in the 2010 text by Bolderston

et al. concerning radiation therapists), the fact there are different branches

of professions must be acknowledged in any research on identity, because

different professional roles will obviously lead to different experiences

even if members of a profession are given the same ‘umbrella’ label that

incorporates all. Additionally, it should be acknowledged that

interpretations of the ‘professional identity’ of H&SC professions tend to be

presented from the viewpoint of other academic disciplines (sociologists,

anthropologists etc.) or from the viewpoint of the professions themselves.

The purpose of the ‘performance’ of the role of any H&SC professional is of

course, for the patients and carers, but their views on professional identity,

and where it may be viewed as succeeding or failing are not evident in the

literature. This may be merely an issue of timing; where the large

influential studies of professions and professionalism were undertaken

from the 1960s onwards, the consultation and involvement of patients /

service users in research has only really been seen in the last ten years,

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since when far less attention has been paid to ‘professional identity’ than

other topics. It may be however that a patient viewpoint on identity may

help all professions to understand how they are perceived by the people

they have trained to help.

In this chapter it has also been established that another key aspect to

understanding ‘professional identity’ is that it is not something an

individual (necessarily) chooses to have, but is an (inevitable) consequence

of becoming a member of a particular profession. And yet such identities

are not static; the roles of the professions change over time and with

different influences (professional bodies, policies, and even public

perception). Shove (2012) refers to social practice when she states that:

With each transition, elements…the details of know-how, the

meanings and purposes of the practice and its characteristics – as

entity and performance - have been reconfigured. (p8)

However, if one considers professionalism to be a ‘social practice’, it can be

seen how discourses of professionalism have shaped professional identities

over time. Additionally, it can be seen that professional identities are to a

certain extent about expectations – what other professionals expect and

what the public (and therefore patients) expect of a profession and a

professional. And it is precisely because professional identity incorporates

these complex and changing elements that those wishing to push for

interprofessional collaboration need to understand it, ensuring that IPE

leads to collaborative practice and is not seen as a barrier to overcome.

The way in which students are socialised into a profession also means that

any identifiable ‘theory-practice’ gap between the theory of what is taught

about IPE and what happens in practice has implications for all professions

and collaborative working. The following chapter therefore considers the

history of IPE, the evidence generated by projects attempting to introduce

IPE into undergraduate, and postgraduate curricula and the linkages made

between professional identity and IPE thus far.

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Chapter Three

Interprofessional Education: Policy, Literature and

Evidence

…there is certainly no ‘one size fits all’. Willingness to adapt to the

various contexts and circumstances of the learning environments

with a range of strategies is likely to prove the most adaptable way

of working in the future.

(Miller et al. 2006, xviii)

3.1 The literature searching process

This chapter examines evidence for the effectiveness of IPE in H&SC

education by reviewing published literature concerning the introduction of

IPE into curricula in various formats; it also examines discussions that

relate IPE to issues surrounding professional identity. An initial literature

search was undertaken at the beginning of the research process with the

thesis proposal (2008). A more systematic search was conducted at the

beginning of 2013, looking at all relevant papers published between 2000

and 2013. The majority of work (over 10,000 papers) published in this

field is concentrated around the mid- to late-2000s; given the need for

literature to be still relevant within the current structures and curricula of

H&SC, papers published pre-2000 were excluded. However, influential

papers published prior to this date, or those that have been recurrently

cited, have also been included in this review. After this date, content alerts

for the Journal of Interprofessional Care and Medical Education were used to

identify further contributions to the field of work.

The literature search itself was carried out using the PubMed databases

MEDLINE and CINAHL, as well as the British Education Index, with search

keywords: ‘interprofessional’, ‘inter-professional’, ‘multiprofessional’,

‘multi-professional’, ‘inter-disciplinary’ and ‘multi-disciplinary’. This

yielded 9,484 results. These were imported into EndNote Web and filtered

for relevance by reading through the abstracts. Certain journals (Journal of

Interprofessional Care, Journal of Integrated Care and Medical Education)

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were also searched by reading through content lists. These processes

resulted in 436 identified papers specifically about IPE initiatives; 121 on

‘readiness’ or attitudes towards IPE; 85 on staff development and faculty

perspectives on IPE; 21 existing literature or systematic reviews; and a

further 120 relevant papers, such as those drawing on theories related to

IPE or which explored relationships between IPE and learning theory.

From this selection, the papers read in entirety (c. 350) were determined

by their availability at my institution of study, but where abstracts

indicated that the paper made a significant contribution to the knowledge

base on IPE, these were also requested and read. Before the literature is

discussed in detail consideration is given to how government policies, its

drivers, and curriculum changes across H&SC all resulted in IPE becoming a

dominant discourse in H&SC education before evidence for its efficacy had

been gathered or agreed.

3.2 Government policies and curricula changes

In the UK, there has been a significant political emphasis on developing

interprofessional working and collaborative care, with a succession of

papers published by the Department of Health (DH) (1989, 1990, 1998)

looking to improve multi-agency partnerships between health and social

care services and related to the modernisation agenda for the NHS (Scholes

and Vaughan 2002; Ross et al. 2005). Political emphasis around the

organisational efficiencies of H&SC services have highlighted the need for

improved ‘joined-up working’, a notion that is generally supported by the

whole political spectrum as a potential way to use resources more

efficiently. Additionally however, there are also political responses to

identified failures of the H&SC system; the need for better teamwork and

communication skills between professions having been recommended in a

number of high profile reports and inquiries, many of which have

investigated failures of H&SC to act to the highest expected professional

standards. The failures of H&SC are to a certain extent therefore in danger

70

of being exploited for political means (again, by either end of the political

spectrum) where political proposals around reforming the H&SC system

become tangled with these failures, and yet H&SC failures do highlight

issues of professionalism. One of the main drivers for improved

collaboration has been the need to improve both outcomes for patients and

patient safety. The Kennedy report into the ‘management of the care of

children receiving complex cardiac services at the Bristol Royal Infirmary

between 1984 and 1995’ (DH 2001), for example, recommends ‘broadening

the notion of professional competence’ through ‘shared learning across

professional boundaries’, and suggested that there should be:

more opportunities than at present for multi-professional teams to

learn, train and develop together. (Kennedy 2001, p445)

The Laming inquiry into the murder of Victoria Climbié by her guardians,

after she had been visited by social workers, recommended that:

The National Agency for Children and Families should require each

of the training bodies covering the services provided by doctors,

nurses, teachers, police officers, officers working in housing

departments, and social workers to demonstrate that effective

joint working between each of these professional groups features

in their national training programmes.

(Laming 2003, p367, emphasis added)

These recommendations were made in high profile public inquiries and

stem from a claim that better or more collaborative working (among many

other things) might have prevented these incidents. However, it should be

noted that these recommendations are vague in nature; for example, the

statements ‘more opportunities’ and ‘demonstrate…effective joint working’

do not propose how such improved team working should be achieved (but

nor was it their remit to do so). Nevertheless, they are often cited as

influential policy drivers in the development of IPE (Thistlethwaite 2012;

Anderson et al. 2010), which, for clarity of definition, can be described as

when two or more professions ‘learn with, from and about each other to

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improve collaboration and the quality of care’ (CAIPE 2002). Nevertheless,

without existing evidence for these recommendations, it still requires a

‘leap of faith’ to assume that developing IPE in itself would automatically

lead to ‘more opportunities’ to learn together, or result in ‘effective joint

working’.

As discussed in Chapter One, the emergence of IPE in the UK as a dominant

discourse for improving teamwork and collaboration in H&SC was also

driven by the policy agendas laid down by the government in the form of

the Health Act 1999 and the Health and Social Care Act 2001 (Cooper et al.

2004). In particular the Health Act of 1999 stated that NHS bodies and

local authorities:

…shall co-operate with one another in order to secure and advance

the health and welfare of the people of England and Wales.

(Health Act 1999, Part 1, Section 27)

Craddock et al. (2013), following Robson and Kitchen (2007) state that the

‘the integration of IPE into prequalifying curricula is mandatory’, as

introduced by the DH and Quality Assurance Agency (QAA) in 2006.

However, the situation is more complicated than this statement suggests.

Barr et al. (2011) highlight that pre-registration IPE is, and has always

been:

…subject to separate regulation within each of the professional

courses in which it is embedded. (p30)

This resulted in most professional courses that wanted to introduce IPE

attempting to meet two or more sets of requirements. What the QAA

published in 2006 was a statement of common purpose for all health and

social care professions, which was based upon benchmarking statements

from all H&SC professions prepared and gathered from 2000 onwards.

Agreed by representatives across many professions, (the Department of

Health, Skills for Health, health authorities and universities) the statement:

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…encouraged shared learning between students from a range of

health and social care professions, but was not to be regarded as a

national curriculum for such learning.

(Barr et al. 2011, p35, emphasis added)

The QAA statement was an agreement in principle across professions,

educators and their regulators that IPE needed to be included at pre-

registration level. This pressure from policymakers and, in particular, the

DH to ensure that IPE was included in all undergraduate training resulted

in responses from professional bodies, most stating that students from

their respective professions would graduate being better prepared to work

in multi-professional teams and across professional boundaries. For

example, the 2010 Standards of conduct, performance and ethics published

by the NMC states that nurses and midwives must:

…work cooperatively within teams and respect the skills,

expertise and contributions of your colleagues [and]…share your

skills and experience for the benefit of your colleagues… consult

and take advice from colleagues when appropriate…make a

referral to another practitioner when it is in the best interests of

someone in your care. (p4)

Similarly the 2009 version of ‘Tomorrow’s Doctors’ emphasised the need

for doctors to both understand and respect the contributions of other H&SC

professionals as well as understand the contribution of interdisciplinary

learning and working to the delivery of effective and safe patient care (GMC

2009).

The ability to work cooperatively across professional boundaries is

therefore now seen as integral to professional behaviour and responsibility

and is clearly something all professions agree contributes to good patient

care. Nevertheless, this does not explain how interprofessional education

became seen as the way this aim would be achieved, and how it became

understood that students from different professions learning together

would automatically result in graduates better able to work together.

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3.3 IPE as a dominant policy discourse

Despite the lack of clear legislation demanding the provision of IPE in H&SC

curricula (although, as explored above, there is much policy pressure in

this area), the dominance of IPE as the (theoretical) method to improve

collaborative practice implies that, at some point it became tacitly accepted

as ‘the way forward’ to achieve the policy aims involved in creating an

interprofessional workforce. Needham (2011) looks at the ‘personalisation

agenda’ in this same context, exploring how:

…a wide range of actors use policy to convey certain meanings,

how far meanings are shared, how some meanings come to be

dominant and how they shape practice. (p14)

Needham notes that for personalisation, the cross-political appeal ‘implied

the emergence of a new policy orthodoxy’ which made it difficult for

anyone to speak out against the agenda being established (2011, p2). The

same argument can also be applied to IPE – that, with the inadequacy of

previous models of professional working becoming increasingly obvious

(and highlighted as the cause for system failures), the need to improve

interprofessional collaboration, and to do so through the education of

H&SC professionals, appeared self-evident. As this chapter reveals,

subsequent attempts to introduce, define and refine IPE varied hugely in

scale and results, but the voice of CAIPE (the Centre for the Advancement of

Interprofessional Education) in the UK must not be underestimated.

Established in 1987, CAIPE was set up by academic advocates of IPE, a

concept that CAIPE helped to develop became the most-widely used and

recognised definition of IPE. ‘When two or more professions learn with,

from and about each other to improve collaboration and the quality of care’

(CAIPE website). The CAIPE website (in 2013) states that:

CAIPE acts on the belief, corroborated by a growing body of

evidence, that well planned IPE can cultivate closer collaboration

not only between professions but also between organisations and

with service users and their carers; collaboration which, in turn,

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can improve care and quality of life for individuals, families and

communities. (Emphasis added)

While the aim of improving care and quality of life is of course vital to any

innovation in H&SC, and is indeed commendable, it is interesting to note

that the language of the Centre is one of ‘belief’ and a ‘growing body of

evidence’ about IPE, as opposed to an existing body of evidence and

underpinning theory. As an authoritative agency both nationally and

internationally, and with strong links the Journal of Interprofessional Care

(one of the dominant academic journals publishing in this area), the ability

of CAIPE to influence how IPE has been perceived and promoted has to be

recognised as important to the way IPE became seen as ‘the answer’ to

improving collaborative working.

Another potentially influential factor in the development of IPE was the

2001 call for bids by the Department of Health to:

HEIs and Workforce Development Confederations in England

inviting joint applications for funding to support ‘common learning

programmes for pre-registration students’. (Barr 2007)

This movement resulted in four ‘pilot sites’ (known as the Common

Learning Pilots) being funded in England by the DH to implement an array

of IPE initiatives:

The Common Learning Programme in the North East (CLPNE),

which sought to develop and implement practice-based IPE

involving multiprofessional groups of students working in teams,

shadowing practice with real clients.

Interprofessional Learning in Practice (ILP) in South East

London, which involved developing a course in communication

and healthcare ethics for students of all H&SC professional

programmes, as well as a practice-based course through which

students would ‘engage each other in clinical practice’.

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The Combined Universities Interprofessional Learning Unit

(CUILU) which aimed to ‘embed emerging practice-based

interprofessional learning pedagogy into curricula for students of

H&SC’ across two participating universities.

The New Generation Project, which comprised three mandatory,

interprofessional learning units (IPLUs) that were assessed and

embedded in all pre-qualifying H&SC programmes across the

project partners. (based on Barr 2007)

Each of the four sites conducted their own evaluations and published

comprehensively about their experiences, see, for example Gordon et al.

2004, Hean et al. 2006a, O’Halloran et al. 2006 and Pearson et al. 2006.

Additionally, the DH commissioned an independent team (though some of

the named Project Advisory Group were associated with CAIPE) to conduct

an evaluation which explored existing evidence for IPE and described in

detail the four programmes of work and their impact, as well as making a

number of evidence-based recommendations (discussed later) for

developing IPE at Macro, Meso and Micro levels (Miller et al. 2006).

However, it was not necessarily evaluations of experiences from these sites

that acted as a catalyst for other institutions developing IPE; as noted in a

monograph detailing the four case studies, many other ‘parallel

developments had begun at much the same time’, and the contribution that

learning from the case studies made was to the already ‘growing, collective

understanding of pre-registration IPE’ (Barr 2007, p72). Nevertheless, the

very fact that the DH invested heavily in IPE pilots could have been an

influential factor in the considerable attention paid to IPE in other areas

(Miller et al. (2006) noted that over £3 million was made available to

support the initiative). It is conceivable that other educational

establishments did not want to be, or even perceived to be, ‘left behind’;

others may have developed their own programmes with the hope that

further funding would be available to develop them. Whatever the case, it

appears that while there was some investment in establishing best-practice

and an evidence-base for IPE, a number of attempts to trial various models

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occurred before evidence was gathered or published, with the effect that

thousands of articles are available on IPE and the ‘best ways’ to teach it, but

still very few contribute to the evidence base on its effectiveness in

improving either collaborative practice or patient care.

While all the recommendations made in the evaluation of the IPE pilots

were of relevance to introducing IPE generally (including a number

concerning the practical aspects of organising IPE), there were four that

were specifically relevant to this research:

There should be a strategic recognition of the need to commit long-

term investment in preparing staff for the role of IPE facilitator.

IPE should take place at least partly in practice settings as

recommended in Working Together, Learning Together

(Department of Health 2011).

Student groupings should normally reflect naturally occurring

professional groupings for those IPE activities that focus on patient

/ client care (whether involving real or hypothetical patients /

clients).

IPE activities should involve students actively learning with, from

and about each other, and include exploration of professional roles

and identities. (Miller et al. 2006, xix – xx)

These recommendations, all discernibly related to socialisation and

socialisation processes, highlight an existing recognition in this field of

work concerned with the importance of staff roles in IPE facilitation and

engagement, and the need for experiences of IPE to be relevant in both

place and context. Furthermore, the explicit acknowledgement of the need

to explore the roles and identities of other professionals also implies that

the relationship between IPE and professional identity is important. The

evaluation found that:

There was evidence of stereotypical attitudes and beliefs amongst

first year students. Medical students attracted more attention than

students from other disciplines, either as a result of other groups’

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prejudices of because their behaviour evoked comment…There

was evidence [in one] case that shared status as students and

neophyte professionals did not engender a sense of commonality

and group purpose, and diversity within the groups served to

exacerbate negative stereotyping. (Miller et al. 2006, xiii-xiv)

Such findings clearly emphasise the need to explicitly incorporate keen

explorations of professional identities as part of IPE, given that exposure to

opinions about other professionals could serve to reinforce rather than

address negative stereotypes.

This section has given one interpretation on how IPE became dominant in

H&SC education policy and curricula, and has taken a summary look at

some recommendations from the evaluation of government-funded pilots

of IPE. However, the reviewed evaluation did not reveal evidence

concerning whether IPE is effective in improving what it is supposed to

improve: collaborative working and, subsequently, patient care. The

following section therefore examines published evidence for the

‘effectiveness’ of IPE, drawing on existing literature and systematic reviews

focused around this topic.

3.4 Existing literature reviews on IPE

A number of existing reviews that aim to examine evidence for the

effectiveness of IPE already exist (Zwarenstein et al. 2000, and updated in

2008; and also updated by Reeves et al. 2010a, Cooper et al. 2001, Freeth et

al. 2002, Barr et al. 2005, Hammick et al. 2007 and Thistlethwaite 2012).

Nevertheless, it should be noted that the later material often draws heavily

on the earlier works. The extent to which it is possible to gather and then

provide evidence pertaining to the impact of a particular working practice,

such as collaborative practice, has been questioned by others working in

this field. In particular questions have been raised regarding whether it

would ever be possible to separate and therefore assess the impact of one

particular ‘practice’ on a patient outcome (Pirrie et al. 1999; Kilminster and

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Zukas 2007). As the reviews of evidence of effectiveness are an important

part of the literature base for IPE they must still be considered here despite

these considerations. Before attention is given to whether these reviews

were able to find evidence of effectiveness for IPE, it is first important to

understand that IPE can take many different forms, which in itself

contributes to the difficulties of gathering evidence of its ‘effectiveness’.

3.41 ‘Forms’ of IPE

Interprofessional education can and has been conceptualised and

subsequently introduced in many different forms. Langton (2009)

classified university-delivered IPE into five main types:

A common curriculum across all professions (for all parts of a

programme).

eLearning in parallel with other courses.

One or more modules inserted into new or existing curricula.

Within clinical practice as one element.

Work-based.

However, Langton also acknowledges that IPE may be a combination of two

or more of these. There are also a multitude of other variables to be

considered, including whether IPE is ‘formal’ – that is initiatives that are

planned to involve opportunities for learning and change through

interprofessional interaction, or ‘informal’ - that is more serendipitous

interprofessional learning (Freeth et al. 2005; Barr et al. 2005). Barr et al.

(2005) also note that whether IPE is compulsory or voluntary impacts

upon engagement. While IPE must still be recognised as an experience

which is interprofessional, defined by Hammick et al. 2009 as ‘a way of

learning and working with others that is respectful of them, and, by

implication, of what they know’ (p3), it must be understood that the term

‘IPE’ does not apply to one single type of initiative but is now understood to

apply to a variety of scenarios. It is in this context then that the following

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discussion on existing reviews of the evidence of effectiveness for IPE must

be situated.

3.42 Exploring the evidence for the effectiveness of IPE

The review undertaken by Zwarenstein et al. (2000) and published through

the Cochrane Collaboration was very specific in its search terms. Firstly, it

aimed to assess the effectiveness of IPE interventions compared to uni-

professional education, and ‘to assess the effectiveness of IPE interventions

compared to no education intervention’ (Zwarenstein et al. 2000, p1). It

also restricted the review to papers that used randomised controlled trials,

controlled before and after studies and interrupted time series studies.

Pirrie et al. (1999) are particularly sceptical of this approach, suggesting

that it is unlikely there will ever be a ‘sufficient number of published

evaluations’ to ever meet the inclusion criteria in order to make the review

meaningful (p305). Indeed in their initial search, Zwarenstein et al. did not

find any studies that met their criteria. The updated review (published as

Reeves et al. 2008, and also as Reeves et al. 2010a) identified six studies

meeting the criteria. However, while the authors consider that the quality

of quantitative IPE research is improving, the paper concludes that:

[a]lthough these studies reported a range of positive outcomes, the

small number of studies, combined with heterogeneity of IPE

interventions, means it is not possible to draw generalizable

inferences about the effects of IPE. (Reeves et al. 2008, p9)

More particularly, the papers call for further, rigorous mixed methods

studies of IPE ‘to provide a greater clarity of IPE and its effect on

professional practice and patient /client care’ (Reeves et al. 2010a, p230).

The review by Cooper et al. (2001) examined only studies concerning IPE

activities that had taken place at pre-registration / undergraduate level, but

also considered studies using both qualitative and quantitative methods.

The authors explored the effectiveness of 30 articles meeting their

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inclusion criteria: the article must be written in English, and the IPE had to

be provided for undergraduates while meeting one or more of the

following aims:

To increase interdisciplinary understanding and co-operation.

To promote competent team work.

To make effective use of resources.

To promote high quality, comprehensive patient care.

(Cooper et al. 2001, p230)

To judge the effectiveness of outcomes of the IPE initiatives, Cooper et al.

developed a model based on Kirkpatrick’s (1967) four-point typology of

educational outcomes (see Figure 3.1).

Figure 3.1: Cooper et al.’s (2001) Hierarchical levels of evaluation of

IPE interventions developed from Kirkpatrick (1967)

RESULTS

Effects on students’ learning environments

(transfer or impact)

BEHAVIOUR

Transfer of learning into individual student’s learning experiences

LEARNING

Effects on students’ knowledge, attitudes, skills and beliefs

REACTION

Evaluation of the learning experience by participants

Source: Cooper et al. 2001, p233

Within this model, each stage represents an increase in the ‘complexity of

behavioural change’, where ‘reaction’ is the lowest level and ‘results’ the

highest and most complex level, at which interventions can be judged to

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have had an impact on students’ learning environments. While

Kirkpatrick’s typology is widely used in literature regarding training, a

number of issues with using such an evaluative tool have been identified,

which also apply to Cooper et al.’s adaptation. Firstly it has been noted that

while the top level of such models are highly desirable to achieve, as they

describe an ‘impact’ of education, they are extremely difficult to assess

(Harden et al. 1999, p558), requiring information on whether students

were able to transfer learned skills into practice (Carpenter 2011).

Additionally, Baldwin and Ford (1988) suggest that in order to truly

understand the impact of the transfer of skills from training into practice,

there are a number of variables that need to be taken into account that are

excluded from the one developed by Kirkpatrick and consequently Cooper

et al. (2001). These include trainee (or student) characteristics,

environmental characteristics (including the organisational climate such as

favourability towards a new initiative) and the ‘conditions of practice’ such

as how the training is delivered. The difficulties of isolating an IPE

intervention have already been noted as problematic (Pirrie et al. 1999),

and the use of Cooper et al.’s model to evaluate IPE interventions can be

further critiqued as having excluded the contextual variables identified by

Baldwin and Ford. Nevertheless the model has been used and is well-cited

in IPE literature.

Cooper et al. themselves used their model to align themes and subthemes

of IPE interventions they reviewed against each of their identified ‘levels of

evaluation’, in order to evaluate both the educational processes and their

effects (2001, p233).

The majority of evaluations Cooper et al. reviewed were short-term studies,

which, following Hargreaves (1996), the authors suggest provided

anecdotal rather than recognised / accepted evidence and outcomes;

additionally, the scale of the studies (which generally did not follow up

what happened when students went into practice) reduced the likelihood

of evaluating the outcomes as reaching the highest level of ‘results’ against

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their model. Nevertheless, Cooper et al. did find that the largest effects of

the IPE initiatives studied:

…were on students’ knowledge, attitudes, skills and beliefs, in

particular on understanding of professional roles and team

working [and that] early learning experiences were most

beneficial to develop healthy attitudes toward interprofessional

working. (Cooper et al. 2001, p235)

Despite positive findings showing that the interventions were high quality

and that IPE may improve attitudes towards collaborative practice, it was

noted that there was little reinforcement of what was learned, and the lack

of longer-term outcomes meant that there was no evidence for the effect of

IPE on professional practice (Cooper et al. 2001, p236). In terms of

understanding the ‘effectiveness’ of IPE, the most positive this study was

able to be was that there were short term changes to knowledge, attitudes,

skills and beliefs as a result of IPE interventions, but no proven longer term

outcomes on either collaborative practice or patient care.

Of all the existing reviews, the book by Barr et al. (2005), an extension of

the review by Freeth et al. (2002), has been especially influential,

principally because it presented a typology (also an extension of

Kirkpatrick’s 1967 model – see Table 3.1) with which to classify

interprofessional education outcomes. Hammick et al. (2007)

subsequently used this typology to carry out their own review.

Using a selection criteria that involved looking at the quality of

methodology and the sufficiency of information provided, Barr et al. (2005)

used their classification to review 107 evaluation studies (of 353 initially

found) (summarised in Table 3.2) of formal and informal IPE (where

formal involves an explicitly planned activity, and informal is ad-hoc

encounters between different professionals). Of the papers they reviewed,

79% concerned postgraduate / qualifying IPE; 19% undergraduate or pre-

qualifying IPE; and 2% were mixed. 54% of the papers reviewed were

from the USA, 33% were from the UK, and 4% were from other European

countries.

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Table 3.1: Interprofessional Education Joint Evaluation Team

classification of interprofessional education outcomes

Level 1 [Learners’] Reaction Learners’ views on the learning

and its interprofessional nature

Level 2a Modification of attitudes /

perceptions

Changes in attitudes or

perceptions between participant

groups and towards the value /

use of team approaches to care of

a specific client group

Level 2b Acquisition of knowledge and

skills

Including those linked to

interprofessional collaboration

Level 3 Behavioural change Individuals’ transfer of

interprofessional learning to their

practice setting and their changed

professional practice

Level 4a Change in organisational

practice

Wider changes in the organisation

and delivery of care

Level 4b Benefits to patients / clients Improvements in health or well-

being of patients / clients

(Barr et al. 2005, p43)

Of particular interest to this study was the absence of studies based on

staff-perspectives, with only four using data collected from staff (either

clinical facilitators or higher education teachers) (Barr et al. 2005, p56).

While acknowledging a likelihood that there is a bias towards publishing

evaluations with positive rather than negative outcomes, Barr et al. (2005)

noted that there was a ‘predominance of positive findings across all six of

the outcome categories’ (p74) and that ‘most studies reported outcomes at

more than one’ of their identified levels of classification (p75).

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Table 3.2: Summary of outcomes after classification of 107 IPE studies

Level Outcomes1 Typified by…

1

(Learner

Reactions)

42% positive

5% mixed

Questionnaire data, information on whether

learners enjoyed the IPE experience, their

satisfaction with the experience and their

rating of the experience

2a

(Attitudes/

perceptions)

20% positive

6% mixed

5% neutral

Questionnaire data, outcomes were measured

in changes in attitude towards teamwork and

other professional groups and / or working

with them

2b

(Knowledge

and skills)

36% positive

2% mixed

Questionnaire data, outcomes concerned

reported changes in knowledge or skills such

as enhanced understanding of roles and

responsibilities of other H&SC professionals

and improved knowledge of multidisciplinary

teamwork / development of teamwork skills

3

(Behavioural

change)

20% positive

2% mixed

2% neutral

1% negative

Often based on simple, self-reported accounts

of behavioural change, these studies focused

on interprofessional cooperation and

communication or development of links

between professionals

4a

(Organisational

practise)

35% positive

6% mixed

2% neutral

Tended to include qualified practitioners who

worked on initiatives aimed at improving

quality of patient care. Reporting measures

included referral practices, inter-

organisational working patterns,

documentation of patient records and reduced

costs

4b

(Patients /

client benefits)

19% positive

6% mixed

5% neutral

These studies used clinical outcome data to

provide insights into the effects of IPE on

outcomes for patients, using clinical outcomes

such as infection rates, clinical error rates,

patient satisfaction data and information on

length of patient stay

1 % of 107 studies. (Adapted from Barr et al. 2005, pp76–79)

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It is possible to see that the classification created by Barr et al. (2005)

(Table 3.2) suggests that there is some evidence for effectiveness of IPE in

improving collaborative practice or patient care, provided one directly

equates ‘positive’ outcomes (where the learner valued or enjoyed the IPE)

with effectiveness.

However, as highlighted, only 19% of the papers Barr et al. (2005) included

were based on undergraduate IPE, which makes it difficult to argue that the

identified outcomes can be used to make a case for the effectiveness of IPE

at pre-qualifying level. Subsequently, the recommendations in the book for

pre-qualifying IPE – namely, that IPE should be taught collaboratively

through competency-based curricula – are acknowledged not to have

emerged through the studies included in the review (Barr et al. 2005,

p143) and are instead based upon existing knowledge of ‘successful’ IPE. It

is therefore difficult to establish what the Barr et al. 2005 review did add to

the knowledge on improving undergraduate IPE.

Additionally, even where suggestions of improvements to patient care were

made (at level 4b), there were perceptible and acknowledged limitations in

the type of evidence provided:

Although data about length of stay is relatively easy to collect, it

does not provide an accurate indicator of an improvement in

clinical care. Indeed, it may suggest that a clinic has increased its

throughput, but not necessarily provided better care.

(Barr et al. 2005, p79)

This also does not take into account the difficulty of isolating the impact of

an IPE initiative over any other activity occurring at the same time,

something that may itself have had an impact on clinical outcomes or on

length of stay. As such, it is difficult to suggest that the learning outcomes

typology presented by Barr et al. provides much more than a useful way of

categorising the outcomes of studies focused on IPE; an observation also

made by Miller et al. (2006).

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The review by Hammick et al. (2007) involved authors who had

contributed to some of the earlier Cochrane reviews on IPE and in the

earlier review by Barr et al. (2005). Using the model presented by Barr et

al. to identify the outcomes of the studies (see Table 3.1), the review

identified the ‘best available contemporary evidence from 21 of the

strongest evaluations of IPE’ to explore the proposition that ‘learning

together will help practitioners and agencies work better together’

(Hammick et al. 2007, p735). The review presents a comprehensive

discussion based upon the 3-P (presage – before learning takes place,

process - during learning, product – the outcome of learning) model of

learning, and identified a number of key messages, lessons for practice, and

implications for future evaluations. Of particular interest to this study, the

need for staff development to enable ‘competent facilitation’ was

recognised as ‘essential’ to the effectiveness of IPE (Hammick et al. 2007,

p748). The review concludes by identifying four papers where IPE had

been evidenced as part of programmes leading to improvements in

screening or illness prevention services. While the review acknowledges

that conclusions are the opinions of the review’s authors, it nonetheless

presents a substantial quantity of learning about ‘some key mechanisms

that act to influence the outcomes of IPE’, one of which concerns how IPE

may change attitudes towards other professionals. (This issue will be

returned to in more detail in Section 3.8 which looks at the existing

literature surrounding IPE and socialisation processes.) However, it is also

noted that the review does not find overwhelming evidence to support the

proposition that learning together results in more effective collaborative

practice.

In a more recent review by Thistlethwaite (2012), which aimed to explore

the ‘context, learning and research agenda’ surrounding IPE, summaries

are given of ‘challenges of interprofessional development’, ‘theoretical

underpinnings’, and ‘the research agenda’. Thistlethwaite’s review is more

of a statement about what knowledge and research already exists rather

than an exploration of effectiveness (or evidence for it), but it is noted that

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one barrier to evaluating the effectiveness of IPE is the wide range of

different activities that can be defined as ‘interprofessional’, such as those

identified previously.

This section has attempted to summarise the most influential and

frequently cited reviews of IPE literature. While many did identify useful

and key learning about introducing IPE, all of the reviews concluded with

expressions of desire to see ‘more research’ in the field to strengthen the

evidence base that would answer more questions about the ‘effectiveness’

of IPE. It is difficult to pass comment on the studies showing no evidence

for the effectiveness of IPE identified in these reviews, as discussions

tended to focus on where learning had been around positive outcomes. In

their review, Hammick et al. (2007) suggest that a note of caution should

be raised concerning possible publication bias where ‘the need to publish

work reporting on positive outcomes might militate against appearance of

mainly negative studies’ (2007, pp748-749), although their own finding

was that negative outcomes were more common in studies looking at

changes in perceptions and attitudes to IPE. This issue is explored in more

detail in Section 3.6. Firstly, however, consideration is given to learning

theories with which IPE has been aligned, to establish what underpins IPE

as an educational initiative.

3.5 IPE and learning theories

The introductory chapter outlined that this thesis uses a sociocultural lens

to explore IPE, which focuses on the situated nature of learning. From the

sociocultural perspective:

…the physical context, the type of participation and the

development of relationships, all work to facilitate learning

through a process of ‘becoming’ a member of the professional

community and workplace. (Kilminster 2009, p38)

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This is clearly only one perspective from which to understand ‘how’

learning occurs, but such a perspective highlights the importance of

understanding the theories that have informed curriculum design and

research, and driven educational methods.

There have been several attempts to align IPE with existing learning

theories and to design it with reference to a variety of theoretical

perspectives. Curran et al. (2010) suggest that ‘constructivist learning

theory has important implications for the design of classroom-based IPE’

(p49), because it proposes that meaning making and, consequently,

learning occur through interaction and dialogue. Working in small groups

for self-directed learning using problem-based learning (PBL) (or case-

based learning – CBL) has also been demonstrated to help students on IPE

modules ‘develop knowledge and language together to build a common

value basis’ (Wilhelmsson et al. 2009, p124). Curran et al. note that using

such approaches as PBL in IPE:

…should draw upon real-life clinical problems to stimulate

interprofessional problem solving and should incorporate small

group, experiential methods of learning. (2010, p49)

This is important, D’Eon (2005) suggests, to ensure that learners can

transfer their classroom-based learning in context to the ‘real-world’.

D’Eon also suggests that IPE learning situations need to be structured using

five elements of co-operative learning and that the process needs to be

approached through an ‘experiential learning framework’ (D’Eon 2005,

p49). D’Eon’s paper (entitled ‘A blueprint for interprofessional learning’)

offers his take on ‘the key educational principles and practices that seem

most suited to [undergraduate] IPE’ (D’Eon 2005, p49). The author argues

that the notion of ‘cooperative learning’ (CL) has previously been

demonstrated as an effective tool to promote learning to work in teams,

involving students working together to reach a common goal. Additionally,

D’Eon notes that the features of CL were identified previously in

descriptions of successful IPE in the work of Parsell and Bligh (1998),

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although these authors had not labelled or identified these features in the

same way. D’Eon’s practice points include using cases (either simulated or

real) to approximate situations in which interprofessional teams will

practice (just as it has previously been argued that the ‘best learning’

occurs in real life contexts – Blumenfeld et al. 1997; Brown et al. 1989;),

and to progressively increase the complexity of practice cases to ‘enhance

transfer to practice circumstances’ (D’Eon 2005, p57). This application of

existing learning theory to IPE appears to take into account many of the

challenges previously identified concerning preparing students to be

collaborative practitioners.

Nevertheless, such an approach requires IPE to be introduced over an

extended period of time (rather than as a ‘one off’ session) and to be

integrated into a curriculum rather than being an optional extra. On a more

practical level, Oandasan and Reeves (2005) discuss the design and

organisational aspects of small group learning, suggesting that it is

important to have an equal mix of learners from each profession to ensure

both good interprofessional interaction and that the group should not be

‘unbalanced’. However, such proposals, while sensible on the surface, also

sound – just like the proposals of D’Eon (2005) – as if they describe an

‘ideal type’ of IPE, where equally-mixed small groups of student

professionals are given an opportunity to explore real cases and to learn

together. While this is not to detract from recommendations made on the

basis of key learning principles, there should also be some recognition that

organising IPE in such a way is probably an unlikely option for many

institutions given that the organisation of much university-based IPE

involved coordination of multiple course timetables and often involves

difficulties in attempting to find appropriate / enough classroom space for

combined cohort numbers (see Section 3.64). As a result, IPE is often

arranged around practical considerations as opposed to being based on

theoretically-driven models.

Owen et al. (2012) published a short paper on Collaborative Care Best

Practice Models (CCBPMs) which were developed to address ‘known

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limitations in existing IPE knowledge- and attitude-based educational

models’ (p153). Drawing upon social and learning theories (including

those on social identity), the purpose of CCBPMs is to enable learners to

explore ‘appropriate collaborative behaviours’ in any given scenario using

a combination of self-reflection and social learning. The actual process of

developing the CCBPMs involves a five step process:

1. Identifying a scenario; targeting learners and associated

clinical guidelines.

2. Recruiting expert panels; providing training in IPE and

collaborative team facilitation.

3. Identifying a list of critical collaborative behaviours for

effective implementation of each step of the guideline, creating

the CCBPM and developing associated assessment tools.

4. Developing learning objectives derived from the CCBPM and

designing, piloting, testing and implementing IPE experiences

that reflect the learning objectives.

5. Assess IPE experience development process and student

achievement of IPE learning objectives.

(Based on Owen et al. 2012, p154)

This approach, which is both driven by learning theory and places

emphasis on contextualising the IPE experience for learners, was argued by

the authors to have the potential to link IPE and specified collaborative

practice more explicitly. However, given the paper was only published in

2012, there are not yet any published reports on the use of such a model

either by those who developed it or by others. As such it remains an

interesting potential theoretical model for IPE, but one so far unsupported

by a rigorous evidence base.

3.6 Themes and variables in existing studies

There are many documented initiatives that have been aimed at enhancing

collaboration between and within groups of students and staff, in a variety

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of settings (Miller et al. 2006). The majority of H&SC professions (and

certainly all those of interest to this study) are represented to some extent

in the IPE literature, although a large majority focuses on nursing students.

Barr and Sharland (2012) suggest that social workers are

underrepresented in the IPE literature and are thus far ‘minority

collaborators’ in both IPE and related research (p204).

The extent to which the documented initiatives are related to any

particular learning theory or based upon models of previously successful

IPE is variable, with many ostensibly just trials of activities conducted at

particular times or with available cohorts of students (either

undergraduate or postgraduate). Existing literature suggests that most

evaluative studies of IPE for undergraduate / pre-qualifying IPE are based

on short initiatives (O’Neill and Wyness 2005; Kilminster et al. 2004). This

section summarises this body of literature with reference to the general

themes identifiable upon reading many studies in this area: issues of

‘readiness’ for interprofessional learning; the evaluation of IPE initiatives;

debates around the timing of IPE (e.g. whether it is better placed in

undergraduate or post-graduate education); debates about whether IPE

should be carried out online or face to face, in classroom-based settings or

in practice settings; and issues of resources and organisation.

Additionally, the question of whether IPE is introduced as a ‘core’ element

of the curriculum or as a voluntary / extra-curricular activity has also been

identified as a factor which may influence outcomes or attitudes towards

its success (Larkin et al. 2013; Curran et al. 2010). Gilbert (2005)

recommends that IPE should be embedded in core subjects through both

teaching and assessment, because it will otherwise have no ‘currency or

uptake’ within a discipline. Barr et al. (2005) also highlight that making IPE

compulsory is important, because it implies a likely higher level of

underpinning institutional support for an initiative than for voluntary

aspects of a curriculum. If made explicit, and where relevant, this issue is

also examined in the following discussion.

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3.61 ‘Readiness for’, and attitudes towards, interprofessional learning

In 1999, Parsell and Bligh developed a questionnaire to assess the

‘readiness of healthcare students for interprofessional learning’ or RIPLS.

The original study invited healthcare students to rate a number of

statements about the desired outcomes of shared learning in order to

assess the ‘readiness’ of the students for these activities. 120

undergraduate students from 8 healthcare professions took part in this

pilot study, which was based upon three sub-scales that explored team-

work and collaboration, professional identity and roles and responsibilities

(Parsell and Bligh 1999, p97). The authors note that given the

discrepancies between the student numbers from the different

departments (professions), the final sample included the entire year group

of three of the professions involved; orthoptist, therapeutic radiographers

and diagnostic radiographers. For a further three of the professions

(physiotherapy, nursing and occupational therapy) a random selection of

15 students from each profession who attended a lecture were approached

to take part, while for medicine and dentistry, similar numbers of

participants were selected but from much larger cohorts (Parsell and Bligh

1999). Consequently the final sample of participants involved a large

representation of some cohorts and a much smaller representation of

others. While this is not necessarily problematic to the results it does need

to be noted as a potential limitation of the research, in that it privileges the

responses of those students from the larger professions who represent a

much larger cohort. The authors describe the final sample as a ‘small’ but

‘acceptable minimum’ for the method of analysis used (exploratory

principal components analysis) (Parsell and Bligh 1999, p99), and the

study made a number of observations and inferences based on their

results:

That there is a need to ‘cultivate positive relationships between

professionals through increased contact before qualification’ with a

corresponding need for the appropriate supporting educational

environment that ‘encourages trust and respect between learners’.

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That there is ‘an area of conflict between the retention of

professional identities through adherence to a discipline-based

approach to learning, and a “readiness” for sharing expertise with

other students through team-based approaches to learning’.

And finally that ‘[c]urrent professional practice reinforces the idea

that some health care roles should be subservient to others’ with

the doctor typically identified as the ‘team leader in patient

management’; however, there is a ‘shift towards the belief that the

team leader should be dictated by the context in which the team

operates’, which may not be the doctor.

(Parsell and Bligh 1999, p98)

Finally, it was proposed that the RIPLS tool may help to provide evidence of

changing attitudes towards team-working and collaboration. After some

queries were raised about the stability of the scales of the original RIPL

scale, McFadyen et al. (2005, 2006) revised and published details of a 4-

factor version of the tool. Use of RIPLS has subsequently been reported in a

number of studies that have developed the tool for a variety of purposes.

For example, some studies have utilised the tool with postgraduate

students (Reid et al. 2006), others have made cross-faculty or cross-

institutional comparisons of the results (Larkin et al. 2013; King et al.

2012) or have explored uses of the tool in other countries (Lauffs et al.

2008). This is just a selection; as part of the literature searching process,

121 papers which discussed ‘readiness for’ or attitudes toward IPE were

identified. The volume of work in this area is interesting given that the link

between actually changing attitudes towards teamworking and

collaboration and measuring the ‘readiness’ of students for it is not always

immediately clear. It may be that as one ‘quantifiable’ aspect of a concept

such as IPE notoriously difficult to measure, changing student attitudes

towards IPE may have been seized upon enthusiastically as a way of

showing some ‘outcomes’ from time invested in IPE programmes.

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In a review of research instruments used to explore interprofessional

collaboration, Thannhauser et al. identify that RIPLS is one of only two

psychometric tools that has been developed and used with large-scale

cohorts, with large numbers of papers describing the validity and reliability

of the tool. (The other tool identified in the same way by Thannhauser et

al. being the IEPS – the Interdisciplinary Education Perception Scale, first

published by Luecht et al. 1990). Nevertheless, Thannhauser et al. also

note a number of limitations of using such tools, including the reliance on

using self-reported data to measure respondent perception, and ‘the

numerous perspectives on IPE that need to be taken into account’ (2010,

p340). Additionally, Thannhauser et al. (2010) note that all the

psychometric instruments they identified focus only on ‘interactional

factors’, where ‘systematic factors’ and ‘organizational factors’ have also

been noted to influence collaborative relationships (Martin-Rodriguez et al.

2005). This is a similar observation to that regarding the model of

evaluation developed by Cooper et al. (2001), and indicates the difficulty of

trying to evaluate one educational initiative in the incredibly complex

context of H&SC practice. As with the model developed by Cooper et al.

2001, RIPLS and other similar tools have been used to explore issues

around IPE and collaborative practice, and it is worth noting the outcomes

of some of these papers even with the acknowledgement that they are only

‘measuring’ part of the picture.

As the result of one longitudinal study measuring attitudes to collaborative

learning and working (not based on RIPLS but on a specifically developed

instrument), Pollard and Miers (2008) concluded that professionals who

had experienced IPE throughout their pre-qualifying (undergraduate)

education were more confident about their ability to work collaboratively

and more positive about interprofessional relationships than professionals

educated on uni-professional courses. This study, which presented data

based on opinions of 414 professionals (275 of whom had experienced the

interprofessional curriculum), was the final stage of a large study which

previously administered a questionnaire to students at three points: as

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they entered a healthcare faculty, during their second year of study, and at

point of graduation (Pollard and Miers 2008, p402). As such the research

responded to some criticisms made against other evaluations of IPE,

namely that they were often based on relatively small-scale initiatives (Ker

et al. 2003) (although the authors acknowledge that in comparison to the

earlier data collection points the response rate had ‘dropped considerably’

– Pollard and Miers 2008, p413). Nevertheless, the findings remain based

on a relatively substantial number of respondents and indicated that

confidence and attitudes towards interprofessional working were

enhanced by pre-qualifying IPE (Pollard and Miers 2008, p414). The

results of the study, however, also indicated that ‘professionals were more

critical of IPE than they had been as students’, which is noteworthy from a

socialisation perspective. This issue is raised again in the discussion of the

findings of this study in Chapter Six.

At least two recent studies, one utilising RIPLS (Larkin et al. 2013) and

another using their own attitudinal survey (Curran et al. 2010) similarly

found that introducing IPE during an undergraduate curriculum did ‘not

appear to have any significant longitudinal effect on attitudes towards IPE’

(Curran et al. 2010, p41) or collaborative practice. However, the three year

study by Curran et al. (2010) exploring attitudes towards IPE also looked at

the satisfaction of students after a voluntary (‘extra-curricula’) IPE module,

and did observe significant differences in attitudes of students from

different professions towards IPE (2010, p51). Specifically Curran et al.

(2010) found that the satisfaction scores were significantly lower for

medical and nursing students than those of the other professions in year

one of the study; significantly lower for medical students in year two of the

study; and, significantly higher for pharmacy students than for medicine

and nursing students in year three of the study. This is consistent with

previous findings from other studies that have suggested that attitudes

towards IPE differ according to professional background. Morison et al.

(2004), for example, in a small scale study involving 30 students, concluded

that student medics viewed IPE as a means to learn only about team-

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working and the roles of other professionals, but otherwise preferred a

profession-specific approach; and that students from both medicine and

nursing viewed IPE as disadvantageous if it was perceived to impede their

own professional learning.

In evaluating a common foundation programme (CFP) for degree students

in medicine, radiography, physiotherapy and nursing, Tunstall-Pedoe et al.

(2003) similarly found that the majority of students had positive attitudes

towards the programme, although the attitude of medics was notably less

positive than all other students: over 70% of medics and over 90% of all

other students felt that ‘learning together would enhance their own

learning and would lead to better patient care’ (p164). Additionally they

found that both perceptions of how IPE affected learning and attitudes

towards each other’s professions became less favourable by the end of the

CFP. While establishing that the ‘overall attitude of medical students to

other disciplines was less positive’ they also noted a ‘significant shift

downwards in AHP and nursing students’ attitudes to the medical students

by the end of term’ (Tunstall-Pedoe et al. 2003, p164). Basing their

discussion on the ‘contact hypothesis’ proposed by Hewstone and Brown

(1986) the authors suggest that when two groups are brought together, it

is possible for attitudes to change if certain conditions are met. In this

instance, however, they suggest that while the CFP did have institutional

support, issues such as ‘time-tabling and traditional geographical

boundaries may have hindered positive attitude change’ (Tunstall-Pedoe et

al. 2003, p170). While this may explain why student attitudes did not

become more positive, the authors did not however identify any other

specific explanation for why the attitudes of students may have become

more negative after the CFP. However the study did conclude that students

arrived at university with stereotypical views of other professions, and that

this was more pronounced when their parents were healthcare

professionals. Despite these apparently negative findings, including some

evidence that early exposure to other professionals did not prevent

stereotypical or ‘tribal’ viewpoints, the study concluded that IPE:

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…must be the way to prepare graduates for an environment where

effective team working is so important, and we believe that IPE

should feature from the very beginning of healthcare courses.

(Tunstall-Pedoe et al. 2003, p174)

This appears to provide more evidence about the way IPE has been

adopted as a dominant discourse as ‘the way forward’ for H&SC. In this

instance, despite the fact that their own study indicated that the initiative

they introduced resulted in some worsening of attitudes towards IPE and

other professions, Tunstall-Pedoe et al. still conclude that IPE is the way to

prepare graduates for collaborative practice.

Carlisle et al. (2004) explored the ‘feasibility of introducing IPE within

undergraduate healthcare programmes’ through a systematic review and

focus-group interviews (p545). Their study involved 34 participants,

including undergraduate and postgraduate students (n=8), patients with

chronic diseases (n=5), academic staff (n=12) and practitioners (n=9).

While drawing on a small sample (the authors acknowledge that ‘the

patient voice’ in particular was probably underrepresented), the

participants were found, similar to other studies of this nature, to strongly

support IPE, while recognising the organisational challenges that present

difficulties for implementation (see 3.54). Of additional interest was that all

focus groups ‘felt it was important to understand how professional identity

could be influenced by IPE’, with discussion focusing on how both students

and qualified staff act as ‘gatekeepers to professional role identity’ (Carlisle

et al. 2004, p550). Such findings, the authors suggest:

…point to the need to start IPE as early as possible, thereby

integrating the evolution of role development into the evolution of

‘other’ role awareness. (Carlisle et al. 2004, p550)

Nevertheless, the authors conclude that further research is required to

establish whether the effects of IPE are variable, depending on the timing of

its introduction into a programme. The issue of when IPE should be

introduced is an identifiable theme in literature (see Section 3.63).

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The substantial body of work on attitudes towards IPE has generated a

wide range of results over the years (unsurprising in different contexts and

with different respondents) and it is worth asking what work looking at

attitudes towards IPE is adding to the IPE field. One methodological

criticism that can be made against all such studies (based upon RIPLS or

otherwise) is that they are based upon self-reported attitudes, which may

be misleading for a number of reasons – for example, respondents wanting

to appear more positive towards IPE to please the researchers, or indeed,

conversely, not wanting to give a positive reaction if peers are also more

negative. Indeed, Pollard and Miers (2008) conclude their own study, based

upon a longitudinal data collection of attitudes towards IPE, by suggesting

that:

…this study reinforces the argument that individuals’ perceptions

of their own educational experience are not adequate for

comprehensive evaluation of IPE initiatives. (p414)

Thus, while RIPLS and similar studies provide interesting contextual

information, even some who have published in this area have called for

further research to establish more conclusively the long-term effects of IPE

on collaborative practice.

3.62 Student evaluations of IPE initiatives

A number of articles focus on describing IPE programmes or pilots, and

contextualise this information with evaluation of the programme. Some

provide detail of resources devoted to providing the courses, but the focus

is usually on evaluations of how students and / or staff (and sometimes

service users) regard these courses (Peloquin et al. 2007; Anderson et al.

2010; Layzell and Chahal 2010). However, such reports are often based on

small-scale pilot studies, and offer little in the way of evidence of the

effectiveness for the IPE initiative they describe. Anderson et al. (2010), for

example, conclude that their evaluation evidence:

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…suggests that it is possible to develop effective practice-based

interprofessional learning opportunities, which meet the learning

outcomes of the different professions drawing on resources within

the community. (p237, emphasis added)

It could be suggested that the potential to develop a learning opportunity

for health professionals in a practice environment was self-evident, and

that this was why the initiative the authors described was developed in the

first instance, rather than being the study’s conclusion. For the evaluation

to be anything other than a description of what occurred, it would have

been useful for readers to be shown an analysis of the effects of the

intervention. Unfortunately, this was not possible based on the use of only

post-course questionnaires, focus groups with students and interviews

with service users, which gathered only opinions about the course and its

effects. This is not a criticism levelled specifically at Anderson et al. (2010),

but rather at the number of IPE evaluations that exist in this format. At

most, these reports are useful for establishing what sort of

interprofessional curricula (or pilots) existed at certain times in certain

institutions. While some papers, such as Peloquin et al. (2007), do make

some recommendations for others wishing to set up similar IPE initiatives,

the problems identified with RIPLS literature are also relevant here: that

the most the reports can offer is contextualising information, in this

instance, about what other IPE initiatives exist and what students thought

about them. If anything, the volume of such reports offer more evidence of

IPE as a dominant discourse regardless of the lack of a solid evidence-base

or accepted theoretically grounded approach.

3.63 The timing of IPE

The ‘right’ timing of IPE – that is, when to introduce it into curricula –

remains a keenly debated issue, with Curran et al. (2010) arguing that

current research in the area ‘has yet to determine an ideal time or process’,

something that has ‘largely been attributed to a lack of methodological

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rigour and longitudinal studies examining such concepts’ (p48). However,

this assumes that work and learning practices can be ‘decontextualised’

(Kilminster and Zukas 2007) and that the impact of timing of one

intervention could be proven to have an impact on patient care much later

on in time. The debates around the ‘timing’ of IPE are therefore considered

here in the context of a query over whether such evidence could really ever

be proved.

Lave and Wenger’s notion of ‘communities of practice’ (explored briefly in

Chapter 2 with reference to identity formation) based on situated learning

theory is sometimes used for understanding debates around the timing of

IPE. Just as when they are developing their own professional identity,

students undertaking interprofessional activities can be seen first as

observers on the peripheries of their own profession, then as

understanding their own role within that profession, and then finally as

interacting with members of other professions, initially as observers and

later as team members (Thistlethwaite and Nisbet 2011). In this way,

students can be seen to learn ‘with, from and about’ each other through

knowledge exchange and knowledge transfer (Thistlethwaite, 2012, based

on Kaufman and Mann, 2007), although again the notion that

‘interprofessional activities’ can be separated from all other elements of

professional learning process might be questioned. Harden (1998)

proposed that first year students have an ‘unsettled’ professional identity,

based on prejudices, and that this results in assumptions about other

professions. As such, there is some debate as to whether it is appropriate

to introduce students to interprofessional activity when they are still at the

periphery of their own professional ‘community of practice’, unable to fully

understand their own role within their own profession, and (arguably)

much less likely to understand and interact appropriately with students

from other professions.

In contrast, Thistlethwaite (2012), drawing on a study by Hean et al.

(2006b), proposes that there is no reason to delay IPE once professional

training has started:

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Most health care students are able to differentiate their own

profession from other groups early in their education, at least in

relation to some attributes, which suggests there is no reason to

delay interprofessional interaction until later in training.

(Thistlethwaite 2012, p66)

While not concerned explicitly with timing, the results of research by

Hammick et al. in (2007) suggested that exposure to IPE usually results in

positive effects in both students’ reactions towards IPE and in changes in

knowledge and skills. This could be interpreted as implicit support for the

assertion that ‘the earlier IPE is introduced the better’, given that one

would want to have students with positive attitudes towards IPE and

collaborative practice as early as possible in their professional careers.

Nevertheless, arguments against introducing IPE early, and in particular

the concern that students are not yet familiar enough with their own

professional roles to be able to meaningfully engage with, or understand,

the roles of others, means that attention must also be paid to the findings of

studies that have introduced IPE initiatives at postgraduate or post-

registration level.

Gaskell and Beaton’s (2010) paper, for example, merely describes an MSc in

Advanced Practice, which is both practice-based and embedded (as

opposed to a pilot), but the authors claim that that:

…IPE at this level facilitates a greater understanding of the

connectivity between professionals working in the health care

system in the UK; a better understanding of the skills and

knowledge base of colleagues; more inter-professional working

and appropriate referrals in the work place. (p274)

Watts et al. (2007) suggest that their work differs from existing studies into

post-registration IPE because the initiative introduced was done so in

active (i.e. existing) clinical teams. The programme involved nine teams

being presented with a series of aims relating to improving team

performance, communication and patient care over an eight month

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timeframe, during which each team had five meetings ‘co-ordinated by an

educational facilitator’ (Watts et al. 2007, p444). Evaluation of the study

was conducted by a series of questionnaires (at zero, four and eight

months). Watts et al. suggest that their results show that IPL programmes

such as the one described, ‘can improve team functioning and raise

awareness of professional roles in established clinical teams’, although the

need for a ‘skilled educational facilitator’ to support the process is also

observed (2007, p447). Nevertheless, it is noted that results need to be

treated with caution as only 42/71 participants completed all three phases

of the questionnaire, and that ‘further research is needed to improve our

understanding of the impact of effective team functioning on patient care’

(Watts et al. 2007, p448). Furthermore, no mention is made of the

transitory nature of health care teams, where even ‘established’ teams are

likely to have junior members who may be on rotation or in their first

short-term posts which may make long term evaluation of, or intervention

with, the ‘team’ difficult. It could be suggested that the transitory nature of

healthcare teams makes a greater case for raising awareness of other

professional roles at undergraduate level, ensuring that students and

subsequently graduates know how to work with different team members at

different times, and how to be prepared for the changing nature of their

‘teams’.

One study by Rice et al. (2010) of a pilot post-graduate interprofessional

intervention on general internal medicine hospital wards in Canada found

no impact on anticipated changes in communication and collaboration

between professionals. The intervention involved one-to-one training for

the senior professionals from each profession on the ward who were asked

to cascade this in a half-hour session with team members. The study’s

findings suggested that despite initial willingness to engage with the

intervention, few front-line staff were made aware of it or supported by

senior staff to engage with it. The primary reasons were cited as the ‘fast-

paced work environment and medical hierarchy’ (Rice et al. 2010, p355),

and in particular that medics on these wards were not used to inviting

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professional opinion from others, and doing so would require considerable

behaviourial changes needing more than a single, half-hour discussion to

implement. The paper concludes that the intervention, which was designed

to be ‘minimally-intrusive’, was ineffective, and that:

In a healthcare setting where face-to-face spontaneous

interprofessional communication is not hostile but is rare and

impersonal, the perceived benefits of improvement are insufficient

to implement simple and potentially beneficial communication

changes in the face of habit, and absence of continued senior

clinician and management support. (Rice et al. 2010, p350)

While based upon a small-scale pilot study, these findings could be

interpreted as being indicative of the idea that if professionals are not

introduced to IPE and socialised into communicating and collaborating

with others from an early stage, a great deal of effort will be required to

address their non-consultative approach to practice. However it could also

be the case that the content of the intervention – a four-step semi-scripted

process that was intended for use during all interactions related to patients

between members of different healthcare professions - was not

appropriate to meet the aims of the programme. Implementing such a

complex and ‘false’ element of interaction into everyday conversation

would be extremely complicated, even if all parties were interested in

doing so.

A study undertaken by Jakobsen et al. (2011) indicated that perceptions of

the most important learning outcomes of interprofessional training differ

according to career stage / over time. The study involved a cohort of 428

students describing the most important outcomes from their experiences

of an interprofessional training unit after they had completed the training,

and asked them again after they had graduated. Jakobsen et al. found that

while for undergraduate students the most important learning objectives

were viewed as ‘uniprofessionalism’ (learning about own profession /

relevance to own profession) followed by ‘interprofessionalism’ (team-

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working and learning about the roles of others), alumni viewed

‘professional identity’ (improvement of professional responsibility and

ability to make decisions) and ‘interprofessionalism’ as the two most

important features of the training (2011, pp444-445). Jakobsen et al.’s

suggestion that this change of opinion may arise from respondents

developing new perspectives based on ‘increased professional experiences’

(2011 p445) is important because it suggests that IPE can have different

aspects valued at different points in a career, and that initial responses

students give might not represent the longer term ‘take home message’.

Where one might have dismissed the study presented by Jakobsen et al. as

ineffective if only the first tranche of evaluation had been carried out, the

longer view showed that introducing the concept of IPE to students in this

instance became more relevant as soon as they were practicing

professionals. Such findings reinforce the notion that there is a need for

more longitudinal evaluation of IPE, as highlighted by existing literature

reviews discussed earlier in this chapter.

Additionally, it should be noted that reports concerning the introduction of

IPE either at undergraduate or postgraduate level do not usually compare

or contrast the two. More commonly, IPE – or an interprofessional

intervention – has been introduced at either undergraduate or

postgraduate level, and it is being discussed in this single context. It is

therefore unlikely that the debate concerning the ‘right’ time to introduce

IPE will advance until it is possible to make longitudinal comparisons of

students introduced to IPE at different points in their careers; this would

be incredibly challenging and probably far less likely to occur when most

courses are now introducing IPE at undergraduate level. To a certain

extent, the way IPE is now considered to be a compulsory element of

undergraduate curricula has made the debate about not introducing IPE

until a postgraduate level irrelevant, even if evidence to settle it was never

forthcoming.

The point at which IPE ‘should’ be introduced in undergraduate courses

has had less attention than the debate concerning whether it is more

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effectively introduced at undergraduate or postgraduate level, although it

has been noted that many institutions ‘introduce IPE early to their health

professional students, often in the context of a large-scale event in Year 1’

(Rosenfield et al. 2011, p471). A study by Cooper et al. 2005 evaluating an

IPE intervention introduced to first year undergraduates across four

professional courses identified that there are specific benefits to

introducing IPE in the first academic year, specifically referring again to

‘the need to start IPE early in students’ training before professional

doctrines have been built into their learning’ (p492). However, it is

acknowledged that IPE is often introduced at a time point which is

‘advantageous from a specifically administrative perspective’ (Rosenfield et

al. 2011, p471), although as is seen in a discussion of the findings of this

paper (Section 3.64) this does not always result in positive outcomes for

participants.

In one final study of note on this topic, a mixed-method student evaluation

of an introductory IPE event, Anderson and Thorpe (2008) explored

whether student age influenced perceptions of interprofessional

interactions. Students from ten professions accessed the IPE event within

six months of starting their chosen professional course; of which 754

(84%) completed a pre- and post-course questionnaire, with 81 of these

students taking part in (uni-professional) focus groups (Anderson and

Thorpe 2008). They found that students who were younger in age

appeared to gain the most from early IPE initiatives (with the exception of

Speech and Language Therapy students who expressed concerns that the

IPE was ‘too early’ in their course), while all graduate entrants also

increased their learning ‘but were more critical of the learning materials,

requesting a more clinically relevant and challenging introduction’

(Anderson and Thorpe 2008, p279). Reflecting that one possible reason for

this was that age can be an indicator for experience, Anderson and Thorpe

(2008) note the importance of considering past experience and maturity

when planning IPE, which has implications when courses have high levels

of graduate entrants for example. As a result of their findings they

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recommend that graduate entrants are paired together ‘and the content

reflect their prior experiences of interprofessional working’ (Anderson and

Thorpe 2008, p280). In addition to the suggestion that early exposure to

IPE is important for its’ effectiveness, the other concluding point to note is

that the relevance of the IPE initiative to the student group is also

important to the likely success of the initiative. However, these two

conclusions may be seen as offering slightly conflicting advice. In order to

ensure that IPE experiences are relevant for all participants, it may be more

appropriate to mix groups of students at different stages in their

professional careers and experiences. This means that some students will

be exposed to a practical element of IPE ‘earlier’ than others; in order to for

some students to be introduced to IPE ‘early’ it may therefore be more

appropriate to introduce the concept rather than the ‘doing’.

3.64 Resources and organisation

A number of papers exist that describe the resources or organisational

challenges of interprofessional initiatives. Peloquin et al. (2007), for

example, present the ‘progress and development’ of an IPE programme,

and report on the lessons learned:

Understand that curricular upgrades in any of the disciplines,

whether related to higher degree requirements or the institution

of distance learning, will constrain student availability and

challenge interdisciplinary efforts. (p5)

There are two recurring themes in terms of resources and organisation

that arise in reports of organising IPE, namely the issues of finding teaching

space large enough to accommodate extended group sizes generated by IPE

and the difficulties of organising IPE sessions with different professions,

who invariably have different timetables (Begley 2009; Solomon et al.

2010) which can be exacerbated by the demands of placements. Mayers et

al. (2006) also discuss both the practical requirements of securing ‘buy-out’

of key faculty team members to ensure staff have enough time to devote to

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developing and sustaining IPE, and the importance of having

administrative support to assist with running multi-professional

interventions.

There is little academic debate to be had about such issues; developing

programmes of work across professional groups perhaps geographically

separated across a campus, institutionally separated across faculties, and

with full timetables is bound to pose practical issues for those tasked with

organising it. Nevertheless, these issues need acknowledging because they

are consistently raised as potential barriers to the development of

meaningful interprofessional contact in educational settings.

Furthermore, the findings of Rosenfeld et al. (2011) also have implications

for the organisation of large-scale IPE activities. Using focus groups,

Rosenfeld et al. explored the opinions of 23 students from five different

professions who had attended an IPE event delivered to nearly 1,200

students each year. They noted that although the students felt there was

‘value and merit’ in IPE for their own professional education, their

recollections of their first IPE experience were largely negative, due to the

size of the event and the ‘poor fidelity of the interprofessional scenarios

employed’ (Rosenfeld et al. 2011, p474). The students reported that the

size of the event meant that they found it difficult to engage in

interprofessional discussion as ‘interaction was rather cursory in nature’

and the scenarios used to demonstrate were ‘limited and forced’, which

meant that the message of improving interprofessional collaboration was

somewhat ‘lost’ (Rosenfeld et al. 2011, p475). As a result of these findings,

Rosenfeld et al. conclude that:

Educators engaged in IPE should ensure that they create

meaningful and relevant interprofessional experiences, which

emphasis clinical correlates. Careful attention should be paid to

the size of the event and the relevance of learning activities.

(Rosenfeld et al. 2011, p476)

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Thus the organisation of IPE initiatives with large cohorts may be not only

difficult, but also less effective – or more difficult to make relevant - than

smaller workshop-based sessions. Consequently, it must be acknowledged

that delivering IPE needs to offer opportunities to stimulate student

interest in collaborative working and not be entirely about convenience or

‘box-ticking’ to get all students in a single place at one time. However, it

should also be noted that there is often an imbalance in student numbers

on different professional courses (i.e. where some year cohorts are of 300

students for one profession and 12 for another), and that putting students

from all H&SC courses in one room at one time may be the only way to

ensure that each profession within one institution have opportunities to

encounter one another. However if this then means that IPE is less

relevant or useful than it should be, then those responsible for arranging

such IPE need to consider carefully for what purpose it is being

undertaken.

3.65 IPE delivered through e-Learning

Given the practical difficulties in finding suitable times and spaces to

accommodate large IPE sessions, it is not entirely surprising that there

have been attempts to deliver IPE online, allowing options such as

discussion boards to facilitate interaction between as many different

learners / professionals as desired without them needing to be present in a

room at the same time. Oliver (2010) reports on the logistical advantages

of using technology for IPE, including the facilitation of more fluid

discussion and allowing students more flexibility in the way they can use

resources (personalisation or learning resources). Nevertheless, reports

on the effectiveness of e-learning-based IPE are mixed, with not all

particularly well-evidenced and many scant in detail (see Williams and

Lakhani 2010; Berg et al. 2010). For example, Berg et al. suggest that:

Distance education technologies have the potential to facilitate

interprofessional education for students, particularly when

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simulation and faulty resources are limited, and professional

schools are not co-located. (2010, pp603–604)

However, the project upon which this claim was based involved a pilot

study involving sixteen students, not all of whom had completed the

evaluation survey. Pulman et al.’s (2009) paper focuses much more on

evaluating the technological tool they used to deliver part of an

interprofessional curriculum for a much larger cohort (n=600), but still

concludes that they were a ‘long way’ from providing the envisaged ‘totally

immersive, engaging, interactive simulated experience’ (p238).

A study by Carbonaro et al. (2008) compared the outcomes of an IPE

course delivered in different formats; the course discussed was initially

100% face-to-face, but was then altered to a blended learning format

where 70% was delivered using technology. The study collected

demographic data and information on computer experience at the start of

the course, and also administered pre- and post-test questionnaire of team

attitudes, knowledge and skill (the University of West England

Interprofessional Questionnaire), ‘random classroom observations and

polling of student perceptions’ (Carbonaro et al. 2008, p28). The first of

three main findings showed that there were no significant differences

between the student groups receiving the different forms of facilitation on

‘team process skills’. However, there were some differences observed in

the team dynamics of the different groups. These were viewed to be

symptomatic of the various formats that the students were using; for

example, students in the face-to-face class would often interrupt each other

during discussions, and this was not possible in an online environment.

Finally, the students in the blended learning class were more positive about

their achievement in one of the class learning objectives, which concerned

increasing understanding of the roles of other health care professionals

and their ability to collaborate effectively with both professionals and

patients. The authors felt that this could not be explained by differences in

the team process outcomes nor skills of the facilitators, which were not

judged to differ significantly, but it is worth noting that students who

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attended the blended learning option were self-selecting (and needed a

computer meeting the requirements of supporting software) while face-to-

face groups were randomly selected to create comparison teams from a

larger cohort of students. The conclusion of the paper was that further

research was required ‘in order to evaluate the effectiveness’ of the

approach (Carbonaro et al. 2008, p31). But there are very few papers

comparing the delivery of IPE across online and face-to-face formats; most

papers concerning online IPE tend to describe it as a course in its own

right.

Clouder et al. (2011) raise one area for concern about their observations on

undergraduates using online discussions as part of an ‘interprofessional

learning pathway’. In the cases they examined, the professions involved

and the scale of the number of students (n=2,800) necessitated the need for

interprofessional e-learning, with students divided into independent,

closed groups able to set their own ground-rules. First year students

studied a scenario over a 4-week period where students were tasked with

‘identifying what they would do or say as health professionals’ faced with a

given situation (Clouder et al. 2011, p114). From their observations of

these discussions (and those between second year students, which were

specifically about issues such as professional roles), Clouder et al. noted an

inclination for all participants to start their responses to previous posts by

agreeing with what the previous person had said, which was consistent

with other research on online discussion forums (Guiller and Durndell

2006). While the study’s aim was not to quantify this, the authors

highlighted that the tendency for online interprofessional discourse to

rarely involve disagreement did not mirror interprofessional practice, nor

prepare students for dealing with professional disagreement:

If groups do not readily feel able to disagree with one another and

debate their different stances to reach a level of understanding

that promotes mutual respect and collaboration, we are missing

the opportunity to help them develop the skills that will prepare

them for practice. (Clouder et al. 2011, p117).

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A later paper by the same research team (Dalley-Hewer et al. 2012)

discusses the need to facilitate ‘meaningful disagreement’ among

participants, noting that this was possible yet challenging, requiring careful

construction of learning resources and expert facilitation.

In their chapter on ‘invoking educational technology in IPE’, Barr et al.

(2011) suggest that while technology may have the potential to be ‘so

powerful in IPE that it is driving the agenda’, they hope that this is not the

case, preferring instead that it structures the directions and trends in

interprofessional teaching and learning. Indeed, the evidence suggests that

while technology may solve some of the practical issues posed by

delivering education to large numbers of students who are geographically

separated (which may assist in learning about the roles of other

professions), its use raises different challenges about whether the

experience of online discussions are close enough to work-based scenarios

to be of use in developing team-working and negotiation skills.

3.66 Classroom versus clinical based IPE

A further debate in the literature is whether classroom-based IPE is as

effective as interprofessional education or experiences occurring within

workplace settings (i.e. in clinical or community environments). There are

also ‘interprofessional training wards’ that offer students from a variety of

H&SC professions an opportunity to work together (with real patients)

under the direction of qualified staff.

One systematic literature review concluded that classroom-based training

for hospital staff from all professions is a ‘recommended way to improve

patient safety’ (Rabøl et al. 2010, p10). However, Sheldon et al. (2012)

suggest that classroom based IPE limits early and consistent exposure to

other professions, allowing exploration of only ‘core competences’

together. In their systematic review of evidence, Hammick et al. (2007)

suggested that there was a need for more evaluation of IPE in both

simulated and real practice settings. While work in this area remains

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scarce, perhaps indicating that formal IPE is still much more likely to occur

in classroom / educational based than in practice settings, there is

emerging evidence that placement-based IPE develops additional learning

opportunities to those found in the classroom, particularly where

interprofessional teams of students provide care while supervised by

qualified H&SC staff (Pelling et al. 2011; Ponzer et al. 2004; Reeves et al.

2002).

Based upon their own experiences of implementing a pilot course in a

clinical environment (in Canada), Sheldon et al. (2012) propose that

universities need to work in partnership with hospitals to deliver more

meaningful, effective and sustainable IPE, which includes student ability to

develop effective communication skills. Similarly, Dando et al.’s (2011)

report on a small-scale pilot of an interprofessional practice placement in

an in-patient palliative care unit (in the UK) notes that the placement was

positively evaluated and that students (n=59) ‘reported an increased

understanding of both their own role and that of others professionals in the

team’ (Dando et al. 2011, p178). While this finding has been established

elsewhere through classroom-based interventions (Hammick et al. 2007)

Dando et al. found that ‘additional learning opportunities’ arose for

students as a result of being in the placement setting, and in particular

involvement in ‘managing a death’ and resultant understanding of the

importance of being part of a multi-disciplinary team during this time

(2011, p181). However it should of course be recognised that such events

may or may not occur while students are in placement settings, and as such

provide learning based upon ‘opportunistic’ occurrences rather than being

based on something that can be planned.

These results support findings from studies of longer-established

interprofessional training wards such as that in Linköping in Sweden

where the majority of students reported their experiences on the ward as

valuable and believe it clarified future professional roles, as well as

resulting in improved understandings of the roles of others (Wahlström

and Sandén 1998; Wilhelmsson et al. 2009). However, this arrangement

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brings its own organisational challenges. Dando et al. note that

comparatively low student numbers in some of the professions means that

mixing student teams can be challenging and may result in some students

gaining more exposure to interprofessional working than others (2011,

p183), which is a similar point to that noted with the difficulties of

organising classroom-based IPE with professional groups of differing sizes.

Again, one of the barriers to advancing this debate is the lack of work

actively comparing the outcomes of classroom-based interventions with

those based in practice. From the sociocultural perspective it would be

argued that it is impossible to separate out the effect of an IPE intervention

in practice with other practice-based experiences, and that there could

therefore never be a satisfactory amount of ‘evidence’ to support the notion

that classroom-based IPE is as effective as workplace learning.

Nevertheless, introducing the concept of IPE and why it is important in the

classroom, before ensuring that the relevance of placement experiences is

reflected upon, does at least allow for students to think about their own

roles as part of collaborative practice – their interprofessional

responsibilities - even where it is not practical or feasible to deliver IPE in

placement-based settings.

3.7 Staff

While a majority of papers exploring IPE focus on the attitudes of, or

impact on, students, there is a growing body of work that recognises the

importance of developing research on, and with, staff involved in delivering

IPE, either reporting on the impact of initiatives designed to support them,

or dealing with their attitudes towards IPE and / or collaborative practice

more generally. This stems from an increasing recognition that ‘many

educators have little personal experience’ of IPE themselves, but that, as

IPE now appears in most health and social care programmes in the UK and

with the GMC encouraging adoption of it, there is an increasing need for

educators to teach or facilitate interprofessional groups (Anderson et al.

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2011, p11). The next section explores both these areas of work in more

detail.

3.71 The need to support staff as IPE facilitators

To some extent, the need to support staff as IPE facilitators should be fairly

self-evident, but has also been confirmed by research studies. A survey

undertaken by Curran et al. (2007) suggested that gender and previous

experience appeared related to the attitudes of faculty members towards

IPE and interprofessional teamwork, with those who had previously

experienced IPE more positive about its potential outcomes. Pearson et al.

(2007, online) identified that some potential facilitators for the Common

Learning Programme in the North East reported feeling ‘ill-equipped’ to

facilitate interprofessional groups, and in particular lacked confidence in

their ability to teach a mixed group, or incorporate students of professions

with which they were unfamiliar into teaching scenarios. The need to train

and support staff who had not previously been involved in IPE or

experienced IPE (as well as those who had) is therefore crucial. Barr et al.

(2011) note that none of the quality standard for teaching in H&SC higher

education has ever included the requirement that the teachers have ‘an

understanding of interprofessional learning’ (p38). Barr et al. also note

that most university and practice teachers had not experienced first-hand

any form of IPE themselves, resulting in much early IPE being facilitated by

unprepared, unconfident teaching staff (p39). Further studies have

established that faculty members not only need preparation to facilitate

IPE effectively (and in particular to bring groups together and to manage

group conflict) but also that ongoing support for faculty is every bit as

important, ensuring that staff do not feel isolated, can sustain commitment

to the IPE teaching, and can ensure that departments can learn from

collective experience (Freeman et al. 2010; Anderson et al. 2009). The

need to train and support staff is also important from a socialisation

perspective, an issue explored in more detail in section 3.8.

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3.72 Staff perspectives on IPE and collaborative practice

In addition to a need to train staff to become effective IPE facilitators, a

body of relevant work taking into account staff perspectives on IPE and

collaborative practice is of interest here. Anderson et al. (2011)

interviewed 13 novice IPE facilitators both before and after their

involvement in delivering (as co-facilitators) an IPE session taking the form

of a classroom-based workshop. Interestingly, and in contrast to findings

from some RIPLS studies undertaken with students, Anderson et al. found

that while only four respondents suggested there was a likely positive

outcome for either staff or students before the IPE, all post-teaching

interviews involved an ‘appreciation for the merits of IPE’ (p14). While

only a small scale study, Anderson et al. propose that one possible reason

for this was that all novice teachers were paired with experienced IPE

facilitators who may have acted as positive role models, and that after

teaching, interviewees may have reflected on the development

opportunities that getting involved in IPE facilitation had or would offer

them. However, the authors also noted that when talking about the

challenges faced while facilitating a group consisting of different

professions, some aligned their comments about dominating or less

forthcoming students to particular professions, which, Anderson et al.

propose highlights:

…their inexperience and inability to become truly non-judgmental

(2011, p15)

In particular, this inability to stem even implicit judgemental comments is

important in the context of this thesis; even when staff are (or claim to be)

committed to the aims and objectives of IPE, it is still possible that what

they say and subsequently what is being ‘learned from’ them is not

compatible with improving collaborative practice.

Baker et al. (2011) reported on an evaluation of a multi-site IPE

programme in North America, which involved interviews with 132 staff

members from a range of professions. During initial analysis, ‘power

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imbalances amongst the professions’ emerged as a key theme, although this

was not one of the original foci for the evaluation (Baker et al. 2011, p100).

Subsequently, taking a sub-set of 25 transcripts representing professionals

from eight different professions, this issue was examined in more depth.

Some limitations of the study are acknowledged, in particular that the

research was based only on those who initially volunteered to take part in

an IPE initiative, leaving the voice of those who did not take part unheard.

Nevertheless, the findings did raise a number of issues for IPE – for

example, suggesting individuals perceived that the different socialisation

processes for each profession affected how professional groups viewed

themselves; while physicians viewed themselves as leaders or decision

makers, nurses, therapists, pharmacists, dieticians and social workers saw

themselves as ‘team members with a holistic approach to care’ (Baker et al.

2011, p100). Additionally, the fact that medics were ultimately

accountable for any decisions was noted by all professions as a way of

legitimising the position of doctors at the top of the ‘health professional

hierarchy’ (Baker et al. 2011, p101). There was also recognition that those

in the medical profession were responsible for ‘setting the tone of local

team culture’, even when they were in relatively junior positions (Baker et

al. 2011, p101). This resulted in a feeling of disempowerment for other

team members. These findings are important in the context of Baker et al.

finding that non-medics in the study perceived that physicians lacked

interprofessional awareness and were reluctant to get involved in IPE.

While one physician claimed that a lack of engagement was due to an

absence of empirical rigour associated with IPE, other participants

suggested this was a ‘convenient excuse’ to avoid engaging in IPE. One

physician admitted to feeling threatened by a potential loss of power,

income, autonomy:

…interprofessionalism is just another word for further diluting the

quality of work that a physician had previously enjoyed.

(Physician quoted in Baker et al. 2011, p102)

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Such concerns, whether legitimate or an ‘excuse’, remain important

barriers to improving collaborative practice and subsequent attitudes

toward IPE. This thesis took as its starting point the proposal that staff

perspectives on professional identity, IPE and collaborative practice were

important, as it was apparent that, without effective facilitation, IPE was

likely to be unsuccessful in its aims. Results from the literature search

discussed in this and previous chapters have also highlighted that current

understandings of the way professional identity develops raise further

questions about the way students are socialised into professions, especially

where it has become apparent that opinions about other professions and

IPE are formed as a consequence of informal learning and not just formal

IPE. The findings of Anderson et al. (2011) and Baker et al. (2011) are

therefore significant for this study, because they show how facilitators and

staff more generally often hold unacknowledged views about other

professions, which might easily ‘leak out’ or become apparent to students

or newly qualified professionals.

The concept of ‘habitus’, as described by Bourdieu (1998), is relevant here.

Habitus is understood as a partly unconscious adoption of rules and values

from our cultural epoch and history, which informs both choices and

actions. Exposure to context in which there is a willingness to engage with

IPE may result in preparedness to work with other professionals.

Alternately, one might envisage a situation where the findings of Baker et

al. (2011) become self-fulfilling, where senior staff suggest that doctors do

not engage with IPE and junior doctors come to believe that ‘doctors do not

engage with it’ and are consequently reluctant to do so themselves. This

does not reduce the need to consider the debate that doctors – or anyone

else – fails to engage with IPE because of concerns over a lack of empirical

evidence about its effectiveness; as has been explored in this chapter, there

remain many questions in this area. This renders the implications of poor

IPE facilitation, or general negative opinions of IPE / collaborative practice,

extremely important and influential. Ultimately it almost does not matter

how effective IPE interventions are proven to be in terms of explicit or

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implicit negative attitudes towards collaborative practice, because without

changes here, there will always remain a barrier to cross-professional co-

operation.

3.8 IPE, socialisation and professional identity

Finally, and arguably most importantly for this study, there is increasing

acknowledgement of a link between socialisation into professional identity

and attitudes towards IPE and collaborative practice. Barr et al. (1999)

suggested that attitudinal barriers to collaborative practice were

attributable to both lack of knowledge and unrealistic expectations about

the roles of other professionals, while Nolan (1995) identifies the way in

which tensions concerning role boundaries and autonomy result in

increased defensiveness in scenarios where team working is necessary.

One of the purposes of IPE at undergraduate level is therefore to ‘prevent

these professional jealousies developing in the first place’ (Carlisle et al.

2004, p545). However, there is some evidence to suggest that students

arrive at university with ‘an established and consistent set of stereotypes

about other health and social care professional groups’ (Hean et al. 2006a,

p162; see also Tunstall-Pedoe et al. 2003), which suggests that some

students are already fixed in how they think about their chosen

professions’ identity, and the identities of others, before being exposed to

the socialising influences of university and placement learning. There is

also an expanding body of work, however, that identifies concerns about

incidents which have occurred during pre-registration socialisation into

professions.

After interviewing 52 pre-qualifying students from across 10 health and

social care professions, Pollard (2008) established that most students had

been exposed at some stage in placement settings to ‘examples of both

effective and poor collaborative working’ (p12). As a consequence, Pollard

identified that some students could have learned ‘inappropriate

behaviours’ with reference to interprofessional working and suggested that

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while students were not necessarily expected to understand the

importance of organisational systems that establish and maintain

interprofessional collaboration, there were implications arising from some

staff in practice also appearing to be unaware of these issues and their

actions in relationship to them (Pollard 2008, pp21–22). As a result of

these findings, Pollard concludes that:

Supporting placement staff to cultivate their own collaborative

practice appears to be a key issue in affecting their ability to

support students’ interprofessional learning and working in

practice. In particular, academic staff may need to negotiate with

senior placement staff in order that appropriate collaborative

opportunities for students can be jointly identified…

(Pollard 2008, p23)

In her review of the theoretical underpinnings of IPE, Thistlethwaite also

suggests that:

…for students to feel positive about interprofessional activities,

they need to be exposed to educators and clinicians who are also

interprofessional. They also need to observe and participate in

authentic team situations in clinical settings, although such

experiences may not be available to all learners. (2012, p66)

One of the difficulties, Thistlethwaite (2012, p65) suggests, is establishing

whether the ‘communities of practice’ in which learners are placed are

actually interprofessional, or whether the professions are ‘working in

parallel in separate communities’, something that hinders IPL and

collaborative practice. Once again returning to the sociocultural

perspective it could be argued that it is extremely difficult to

decontextualise the experience of being a member of one ‘community of

practice’ from all other practice and educational experiences, regardless of

whether it is interprofessional or otherwise. However, combined with the

emerging evidence that interprofessional experiences on placement are

more effective demonstrators of collaborative practice than classroom-

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based initiatives, the findings of both Pollard and Thistlethwaite provide a

powerful message for all those wishing to establish IPE in undergraduate

curricula.

Furthermore, in their ‘best evidence review’, Hammick et al. 2007 noted

from the studies they explored that:

Participants bring unique values about themselves and others into

any IPE event which then interact in a complex way with the

mechanisms that influence the delivery of the educational event.

(p748, emphasis added)

Thus, while not explicitly making reference to ‘identity’, self-conceptions

were recognised as important in the context of IPE delivery. In addition,

the review established evidence suggesting that perceptions and attitudes

towards others could deteriorate after IPE (but with the caveat that ‘this is

unlikely to be across the whole cohort’ – Hammick et al. 2007, p749).

Nevertheless, there is a potential to worsen attitudes towards other

professions in terms of ‘applying knowledge and skills in practice’;

significantly, the review established that:

…changes in perceptions and attitudes [towards other professions]

are more likely to show mixed results than the other outcome

measures (Hammick et al. 2007, p749)

This is important in the context of the review’s other findings about IPE

being ‘generally well received by participants’, and that, resultantly, IPE

‘enables practitioners to learn the knowledge and skills necessary for

collaborative working’ (Hammick et al. p748); this implies that IPE is less

able to influence attitudes and perceptions towards other staff members

than it is to, say, teach them team-working skills. The significance, if this is

true, is that IPE alone may not be enough to develop sustainable

collaborative practice where barriers concerning negative attitudes

towards other professions persist.

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3.9 What next for IPE?

A recent discourse analysis exploring interprofessional collaboration has

raised questions for H&SC education by identifying that two separate

discourses concerning ‘interprofessional collaboration’ exist and are in

simultaneous use: utilitarian and emancipatory (Haddara and Lingard

2013). The utilitarian discourse, based in positivism, is identified as being

concerned with the search for evidence that interprofessional collaboration

improves patient care and outcomes. The emancipatory discourse

however, from a more constructivist approach, views interprofessional

collaboration as necessary to providing a ‘means to diminish medical

dominance’ (Haddara and Lingard 2013, p4). The authors suggest that all

clinicians and educators involved in collaborative interprofessional

initiatives may find it useful to ‘acknowledge the existence and legitimacy

of both discourses’ (Haddard and Lingard 2013, p6). Both the identified

discourses are evident in various parts of the literature discussed

throughout this chapter, and while there was no obvious tension presented

in any of the literature examined concerning those delivering IPE pulling in

different directions, the recommendations of the authors to ensure that

everyone ‘is on the same page’ regarding the aims and purpose of

interprofessional collaboration are a good starting point.

In 2004, Carlisle et al. concluded that:

Little empirical work exists on the potential effects of IPE on

patient outcomes. Much of the current work focuses on

educational outcomes…and any effect on healthcare outcomes

appears to be limited to anecdotal evidence on students’ career

choices… (p550)

This review has, to a certain extent, sought to establish if this statement

holds true, as this has certainly been the conclusion of more recent studies

(Khalili et al. 2013; Reeves et al. 2010b; Zwarenstein and Reeves et al.

2006). Exploration of existing literature reviews on this topic highlighted

both the paucity of studies contributing to evidence of the impact of IPE on

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patient outcomes, and also the difficulties of producing convincing

empirical work in the area, owing to the number of initiatives labelled as

‘IPE’, as well as the difficulty of isolating effects of an educational initiative

from other changes occurring in a health service at any particular time.

Existing studies reviewed specifically for this chapter also appear to

reinforce the notion that most work on IPE remains focused on educational

outcomes.

The ‘correct’ timing of IPE is one of the key themes in the IPE literature. As

well as being problematic from the perspective that it is difficult to

decontextualise one intervention or experience and claim that this was

what had the impact on patient care, it might also be proposed that this

debate might not arise if one considered ‘interprofessional responsibility’

as part of each individual professions’ identity. If one is socialised into a

profession where an understanding of the importance of interprofessional

roles and responsibilities was seen as an everyday part of a professional

role (as indeed it is) and ‘taught’ as such, it would no longer need to be seen

as something ‘extra’ that requires specific initiatives to become effective.

As such, the need to develop an ability to work as an effective collaborative

practitioner might be introduced earlier rather than later in health and

social care curricula. Nevertheless, as has been established here, whether

or not IPE is the way to achieve this (even in part) has been theorised as

depending on the scale, relevance and applicability of the learning

scenarios for all professions taking part. Khalili et al. (2013) propose that

what is required is a shift towards ‘interprofessional socialization’ (IPS) so

that educators may help students develop a ‘dual identity’ that involves an

‘interprofessional identity’ as well as their existing professional identity.

This, they suggest, would help overcome the barrier of uniprofessional

identity to interprofessional collaborative person-centered practice. To

achieve this, Khalili et al. propose using an ‘interprofessional socialization

framework’, a three stage iterative process by which it is proposed learners

can break down barriers, learn about interprofessional roles and

collaboration, and develop a dual identity (although the framework is yet to

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be empirically tested). Given my own understanding of identity as

something that is fluid and multiple at any particular time, I would question

the need for health professionals to develop a ‘dual identity’ and would

instead propose that ‘interprofessional responsibility’ be taught and

considered to be a core part of each uniprofessional identity. However, the

notion of IPS is useful as a discussion tool, and could easily be used to

advance debates concerning how best to improve the development of

learners for collaborative practice, including ensuring that IPE is seen and

undertaken as more than a single, one-off intervention.

Finally, in the context of a huge amount of academic debate around IPE, it is

also worth observing that collaborative practice is something that has to

occur regardless of what IPE interventions students have been through, or

when and where. To a certain extent, considering ‘collaborative practice’

and ‘IPE’ as separate ‘initiatives’ to be achieved may pose more problems

than they solve. In the UK, these are concepts that have risen to

prominence due to failings in the H&SC systems, because they have been

perceived as lacking; they have become academic concepts, but in reality

professions in health and social care have to work together on a daily basis

regardless of how their work is labelled, and indeed there must be many

examples of doing so effectively for them to achieve their daily tasks. When

H&SC professions fail to work together well, or fall into ‘tribalistic’

behaviour, there are huge implications for patient safety, as indicated by

the reporting of events concerning hospitals in the Mid Staffordshire Trust.

Clearly, H&SC professionals need to learn to collaborate and work together.

However, it could be questioned whether the concept of IPE and all the

debates about how to introduce it, detract from achieving its aim, because

people view it as an additional entity separate from core H&SC curricula

rather than as a vital part of H&SC professional identity.

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Chapter 4

Methodology

This chapter describes in detail the methods and approach used to address

the research questions defined in Chapter One and the issues surrounding

these questions discussed in previous chapters.

4.1 The importance of staff perspectives

As the work introduced in Chapters One and Three has already suggested,

there is some recognition of the idea that, for IPE to be successful, there

needs to be engagement from both academic and practice staff, as well as

students who undertake IPE initiatives or have IPE-based activity in their

curricula. Thus, to add something of value to the already large volume of

work on perspectives of IPE, it was important to seek out the

underrepresented voice of qualified staff.

There are, however, a number of implications of conducting research with

staff instead of students. As Denscombe (2010, p108) highlights, ‘all

research designs have their limitations’, and in this instance that arose

from the fact that both practicing and academic health and social care staff

work in time-pressured environments, and as such the methods used

needed to be appropriate in terms of the time commitment asked of

research participants. The consequence was that methods used had to be

time efficient; gathering the most data in the shortest time possible, so as

not to burden participants with significant time commitments, either

during working hours or from personal time.

Nevertheless, as suggested in Chapter One, conducting the research with

qualified staff was more appropriate in the context of identity being

something that develops over a period of time (Breakwell 1986) with

professional identity something that is achieved through socialisation into

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that profession (Cohen 1981; Moore 1970). While conducting the research

with health and social care students may have been easier as they may

have more time to participate in research, the results would potentially

have been different and presented an ‘incomplete’ picture. Students, it has

been argued here and elsewhere (Howkins and Ewens 1999; Wenger 1998;

Becker et al. 1961) are still being socialised into their profession, as well as

possessing an identity as a student health or social care practitioner.

Students would also not yet be entirely ‘independent workers’ and can only

have experienced working practices on placement settings. As such, not

only would it have been irrelevant to discuss the impact of IPE on their

professional working practices, research with those with a ‘student’

identity would have added a further complication to understanding how

research participants perceived their professional identity and that of

those around them. Despite practical limitations resulting from this

decision, it was therefore more appropriate in the context of debates

around identity development to conduct the research with qualified staff.

4.11 The practicalities of gaining staff perspectives

The decision to conduct the research with practicing health and social care

staff meant that ethical approval had to be gained from the relevant bodies

(see Section 4.2). While there was a standardised and centralised process

to gain access to NHS employees in the form of the Integrated Research

Application System (IRAS), Leeds Local Authority stated that no such

standard process existed to gain permission to involve staff employed by

Local Authorities (with social workers being of interest to this study) and

that, while no specific permissions were needed to conduct a survey with

anonymous social workers, permission was required to interview them.

Subsequently, a set of forms was sent concerning research with social

workers relating only to gaining permission to access client notes and files.

Calderdale Council gave the same advice regarding permission to involve

social workers, but were unable to provide any forms. Despite several

attempts to find someone who could assist with this issue, no satisfactory

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response was forthcoming. As a result, it was not possible to interview

practicing social workers. This was particularly disappointing because, as

highlighted in Chapter Three, social workers have been under-represented

and are perceived to have been ‘minority collaborators’ in IPE and related

research (Barr and Sharland 2012, p204). Nevertheless, after four months

of attempting to find out how to gain permission to include them, it was

apparent that this would take more time than was realistic for the sake of

including one profession. It was still possible to include social workers in

both surveys and to invite social workers employed as academics to take

part in interviews, and so their views are not missing entirely from the

research; but the inability to include practicing social work staff as

interview participants is acknowledged as a limitation of the research.

4.2 Ethics

In order to survey and interview staff employed by the NHS, ethical

approval was sought from IRAS, which was necessary under arrangements

for ethical review at the time the fieldwork was completed. Bulmer asserts

that in the NHS, ‘ethical review is an established part of all research with

patients and staff, whether biomedical or social and economic’ (2008

p158). Such ethical approval protects participants and the liability of

government or public sector departments (including NHS settings) in

which research might take place (see Smyth and Williamson: 2004 p212).

Ethical approval was granted by the Leeds East Research Ethics Committee

in June 2010. I attended the panel in person and was asked to provide a

few minor points of clarification. A copy of the research protocol submitted

and the approval letter are included as Appendices 1 and 2. Research and

development approval was then sought from Leeds Teaching Hospitals

NHS Trust (LTHT) through a Site Specific Information form. Given that it

was impossible to state which staff would volunteer for interviews (and

therefore to know which Heads of Department should be approached for

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consent), the head of the R&D service signed the project off on behalf of all

departments at LTHT, with final approval achieved in September 2010.

In March 2012, ethical approval was granted by the University Research

Ethics Committee for the surveys and interviews with academic staff; a

copy of the approval letter is included in Appendix 3.

4.3 Approach to research and mixing methods

There are many approaches to conducting research. In a caricatured view,

those researching from a positivist approach place more emphasis on data

gained from the ‘testing of theories’ and quantitative methods, whilst

interpretivists favour qualitative methods (Alexander et al. 2008; Gilbert

2008). Interpretivists usually argue that the social world can only be

known through exploring people’s perceptions of it (Neuman 2003; Scott

2002), and research undertaken from this standpoint tends to look for only

‘local, historically contingent meaning’ (Alexander et al. 2008, p138).

However, many researchers take a pragmatic approach, and can see the

value of a variety of research on its own terms, resulting in the use of a mix

of both paradigms and methods (Alexander et al. 2008; Mason 2006;

Bryman 1988).

There are many justifications, and discussions of justifications, for adopting

a mixed methodology approach (see for example Bryman 1988; 1992;

Brannen 1992), but Hammersley (1992, p39) suggests that ‘the distinction

between qualitative and quantitative is of limited use, and indeed carries

some danger’. Hammersley’s argument is that to break down research into

dichotomous viewpoints oversimplifies decisions and standpoints and that

selection of a position on research ought:

…to depend on the purposes and circumstances of the research,

rather than being derived from methodological or philosophical

commitments. (1992, p51)

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The approach adopted for this study therefore utilises a mixed

methodology, based upon the perceived value of different methods to

achieve data collection for different aspects of the research questions.

It must be noted, however, that the mixing of methods has its own

consequences. Brannen, for example, suggests that:

The combining of different methods within a single piece of

research raises the question of movement between paradigms at

the levels of epistemology and theory. (1992, p3)

On a more practical level, Kvale highlights that there are issues of

interdependence between methods that are chosen, suggesting that ‘a

decision at one stage has consequences that both open and limit the

alternatives available at the next stage’ (1996, p99). Nevertheless, utilising

a mixed methodology approach was important to achieve the range of data

required to answer the aims and objectives of the research. The following

sections discuss in detail the actual methods used and why, as well as any

limitations or challenges that using such methods involved.

4.4 Research Phases

The research was carried out in two phases, with phase one consisting of

the survey and phase two consisting of semi-structured interviews.

Additionally, the research was split, so that the phases of data collection

were conducted first with practicing H&SC staff, and then with academic

staff. This was primarily for practical reasons; having to gain IRAS ethical

approval to conduct the research with NHS staff was known to be a longer

process than gaining ethical approval to conduct the research with

academics. Therefore, gaining IRAS approval and getting this part of the

research underway was prioritised to ensure the research was not delayed

by the ethical approval process. Additionally, while the survey tool

remained more or less the same for NHS staff and academic staff (and was

intended to be, see Appendices 4 and 5), the interview schedule changed

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(see Appendices 6 and 7) as parts of the interviews with academic staff

were used to collect data for the case study element of the research on the

ALPS CETL. As such, it was also important to keep the two stages of data

collection separate for both conceptual and organisational purposes, so

that interview data did not become muddled as a result of two different

interview schedules being used simultaneously. The phases of the research

were as follows:

Phase 1a – Online and paper survey of NHS / practicing staff

Phase 1b – Online and paper survey of academic staff

Phase 2a – Semi-structured interviews with NHS staff

Phase 2b – Semi-structured interviews with academic staff.

4.5 Surveys

This research aimed to do more than ‘typical’ studies of IPE which explore

‘before and after’ perceptions of working with other professions (see

Chapter Three), and aimed instead to collect perceptions about, and

experiences of, IPE from a large number of professionals from different

H&SC backgrounds. Using a self-completion survey seemed the most

appropriate method to achieve this, as surveys enable the acquisition of

information from a large number of people distributed over a wide

geographical area more efficiently (in terms of time and money) than by

using any other method of data collection (Simmons 2008; Sapsford 1999).

Sapsford notes that what differentiates surveys from other types of

research is that they involve systematic observation or systematic

interviewing, often involving the researcher dictating the range of answers

that can be given:

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Standardization lies at the heart of survey research, and the whole

point is to get consistent answers to consistent questions.

(1999, p4–5)

The purpose of using a survey as part of this study was to use the

methodology to full advantage to collect this standardised data for the

three types of information associated with surveys:

basic facts/descriptors such as age, gender and occupation;

information on behaviour (what people do);

people’s judgements and preferences (their opinions).

(see Gillham 2008, p2)

It is worth noting at this juncture that other studies exploring professional

identity and attitudes to interprofessional education have already

successfully used surveys, and as such it was also a ‘tried and tested’

method to generate relevant information for the study. In 1986, social

psychologists Brown et al. published a highly influential and much-adapted

scale to explore intergroup rivalry in a paper factory. They asked

respondents to rate how strongly they identified with aspects of being part

of their ‘group’ within the factory setting, with a view to exploring

intergroup differentiation and rivalry. The methods they used to develop

their scale (for which they reported both validity and reliability data) were

based upon previously developed social psychology measures. While this

study did not aim to conduct a piece of research grounded in social

psychology, nor to replicate one, the study by Brown et al. was useful in

that it showed how to structure statements that would elicit responses

describing the extent to which respondents identified with their

occupational role and ‘group’. For example, among other things

participants in Brown et al.’s study were asked to rate on a five point scale

whether they identified with their work group (‘I am a person who

identifies with the __________ group’); whether they felt they belonged to a

group, whether they were glad to belong to a group or whether they felt

held back by belonging to a group (Brown et al. 1986, p276). This was

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something I wished to explore as part of this study, particularly with

reference to strength of feeling about having a ‘professional identity’.

Additionally, the ‘Readiness for Interprofessional Learning Scale’ (RIPLS)

(Parsell and Bligh 1999; Parsell et al. 1998), and the ‘Interdisciplinary

Education Perception Scale’ (IEPS) (Luecht et al. 1990) as discussed in

Chapter Three, are much cited and adapted scales (see for example

McFadyen et al. 2005 and 2006) used to explore attitudes toward, and

perceptions of, interprofessional issues. Again, the success of these survey

instruments made it apparent that people are prepared to respond to

attitude statements about the fairly complex subject of IPE.

Designing the survey was an iterative process completed in several stages,

to ensure that basic errors of questionnaire design were avoided, and to

ensure that the questions used were reliable and valid measures (Fowler Jr

2009; Oppenheim 1992). Both reliability and validity are ‘technical terms’,

and while overlapping, are distinct and of great importance to

questionnaire design (with both terms derived from measurement theory

and psychometrics) (Oppenheim 1992, p144). Oppenheim states:

Reliability refers to…consistency of a measure, to repeatability, to

the probability of obtaining the same results again if the measure

were to be duplicated. Validity…tells us whether the question,

item or score measures what it is supposed to measure.

(1992, pp144-145)

It should be acknowledged that ensuring the reliability and validity of

factual questions is different from ensuring the reliability and validity of

subjective ones (Fowler Jr 2009; Oppenheim 1992), but other than asking

for gender, age and profession details and training (which are not

verifiable, but can be requested in such a way as to avoid ambiguity), this

survey was more concerned with subjective questions in the form of

opinions concerning IPE and professional identity. Consequently, in terms

of ensuring as far as possible the reliability of the subjective questions, this

involved avoiding questions with incomplete wording; avoiding leading

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questions and / or prompts; and ensuring that question terms that were

fully defined and avoided multiple questions (see Fowler Jr, 2009, pp88-

94).

Ensuring the validity of subjective questions is a little more complicated, as

there is no external criterion by which to judge validity:

…one can estimate the validity of a subjective measure only by the

extent to which answers are associated in expected ways with the

answers to other questions, or other characteristics of the

individual to which it should be related.

(Turner & Martin 1984 discussed in Fowler Jr 2009, p110)

Fowler Jr goes on to suggest that for subjective questions to be valid, they

first need to be made as reliable as possible, ensuring no ambiguity of

wording (as outlined above) and that scales used are i. appropriate; ii. only

deal with one issue; and iii. are presented in order (Denscombe 2010,

pp143-149; Fowler Jr 2009, p110; see also Oppenheim 1992, pp144-149).

Additionally, given that some respondents tend to avoid extreme

categories, thought must be given to the number of categories in every

continuum; too many categories make it difficult for respondents to

discriminate their feelings between one category and another, while too

few may force a respondent into a response they do not truly agree with

(or force them to opt out of the question using the ‘don’t know’ option)

(Fowler Jr 2009). Using multiple questions with different forms helps to

iron out idiosyncrasies and is claimed to improve the validity of the

measurement process (Fowler Jr 2009; DeVillis 2003). Reviewing

questions on several occasions and after each version of the questionnaire

draft was therefore important to ensure that the questions were as ‘reliable

and valid’ as possible, or rather that the design of the questions did not

cause issues for the reliability or validity of data.

After the drafting process was complete, the survey was piloted as a paper

questionnaire with eight H&SC professionals, who represented a mix of

professions, some of whom had academic roles and some of whom were

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practicing members of their profession with no academic roles. The

piloting of surveys is an established part of good research design, which

allows researchers to trial their research instrument design (Denscombe

2010) and to test how questions work in the ‘real world’. Those involved in

piloting the survey were also asked to provide feedback on any questions

they found difficult to answer, or if they had perceived issues with question

wording. None of the pilot respondents highlighted issues of this nature,

but as a result of the piloting process further comment boxes were added

where participants had written comments after the questions without

being asked for them (Appendix 4, questions 8a, 8b and 14).

4.51 Sampling

Sapsford (1999) highlights that in the ‘real world’ it is unlikely that

researchers running social surveys have a ‘complete and accurate’

sampling frame (that is, a ‘complete and accurate list of the population to

be sampled’) and that the practicalities of undertaking social research often

dictate the sampling method (1999, pp81-100). This survey was no

different, and there were two key features that led to decisions taken on

sampling: i) the practicalities of the population to be sampled; and ii) the

stipulations laid out in the ethical approval process. Nevertheless as is

outlined in detail in Section 4.53, the survey did achieve a high number of

responses representing a large range of professions.

The research was designed in such a way that any practicing or academic

member of H&SC staff in the world could take part. However, this clearly

amounts to countless people, with a hugely diverse range of backgrounds

and experiences. Consequently, for the research to become more focused,

it was necessary to define the population of potential respondents as

‘practicing or academic members of H&SC staff in England’. This was a

logical choice, not least for the practical reason that the research was

undertaken in England; but also limiting the research to one country meant

that all respondents were working within one health system (albeit an

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extremely diverse one) and one education system, which, it was assumed,

would ensure that respondents’ experiences were more comparable than if

they had been working across a range of countries incorporating multiple

health and education systems. Limiting the potential population further to

just those members of staff working within one health trust / local

authority area was another possibility, but this would have given rise to the

possibility of being unable to recruit enough people take part.

As part of the ethical approval process, it was stipulated that the researcher

could send copies of the survey only to existing contacts, or to advertise the

survey on relevant web-based discussion forums. (This was the case for

the survey used with practicing H&SC staff and the version used with

academic staff.) This clearly had implications for the sampling method

used, which, under such a restriction, could only be a ‘haphazard’ sample,

consisting of volunteers who had seen the study advertised (either by

email or on a web forum) (Sapsford 1999, p90). It also meant that the

study was reliant upon the ‘snowball’ sampling method, which is defined as

when:

…the researcher samples initially a small group of people relevant

to the research questions, and these sampled participants propose

other participants who have had the experience or characteristics

relevant to the research. (Bryman 2012, p424)

There are several implications for the data generated by this project having

used these methods. The first is that the majority of respondents recruited

through contact with myself or a colleague helpful enough to forward the

questionnaire are more likely to be involved or aware of IPE than a

‘random’ selection of staff would be. Given that myself and many of my

colleagues work, or have worked, on IPE related projects, it is probably

accurate to assume that many of our contacts will be aware of this, if not

directly involved themselves. Secondly, as Sapsford (1999, p90) notes:

…[t]here is clearly no good reason to suppose that those who

choose to volunteer are a random subset of the population which

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includes volunteers, non-volunteers and those who did not even

see the notice or advertisement.

It is also probably an accurate assumption that many people volunteering

to take part in a study for which there is no material reward for themselves

are more likely to have an interest in the topic being surveyed about than

those who did not feel inclined to volunteer; indeed, there are many studies

which have explored the differences between volunteers and non-

volunteers (see, for example, Rosnow and Rosenthal 1976), the conclusions

of which, however, are applicable regardless of sampling or research

methodology. Nevertheless, in this instance, it is worth noting that other

than those recruited via email, other participants in the survey were

members of profession-specific online discussion forums. It is possible to

make an assumption that these people already differentiate themselves

from non-members of such forums by using their spare time to take part in

such work / profession related activities.

Finally, ‘choosing’ this sampling method meant that it was not possible to

calculate a response rate to the survey, as there was no way of knowing

how many people forwarded the email advertising the survey and to how

many people the original recipients sent it on to.

However, these issues are only problematic if results from the survey were

intended to make claims about the ‘population’ they represent. Given that

the topic of the study is related to personal experiences of IPE and

perceptions of professional identity, I would suggest (regardless of any

concerns with the sampling method) that it would be inappropriate to

make generalisations about the H&SC staff population from my findings.

The survey method adopted here was a way of collecting a larger volume of

data concerning personal opinions and experiences than could ever be

done with qualitative methods alone, and to provide some contextual data

for the development and analysis of the interview and case study work, but

it was never intended to be the only source of data to ‘answer’ any of the

research questions.

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4.52 Distribution

The survey was distributed in two formats: online and on paper. The

online survey was distributed via email to colleagues who then circulated it

to colleagues et al. (see discussion of snowball sampling in section 4.51),

and was also posted as a link on some profession specific online discussion

forums. The survey was hosted on Bristol Online Surveys (BOS). The

paper-based survey was distributed in the same way as the email link,

passed to colleagues who were willing to forward to those interested in

taking part. All paper versions of the survey were sent out with a freepost

envelope to ensure no cost implication for participants. The online and

paper versions of the questionnaire contained the same questions

presented in the same order. As the BOS system allows for only simple

routing of questions and follow-up questions, this sometimes dictated the

question numbers, but did not affect the question content.

There are numerous academic works concerning the advantages and

disadvantages of both online and paper versions of questionnaires.

However, as the limitations set down by the ethical approval for the project

determined the sampling and recruitment method of the survey, the

decision to attempt to collect data via two methods was a pragmatic one, as

using a mixture of modes to collect data:

…offers opportunities for compensating the weaknesses of

individual modes, for example, increasing response rates and thus

eliminating non-response biases.

(de Leeuw 2005 quoted in Vehovar and Manfreda 2008, p185)

Best and Kreuger (2008) suggest that when designing online studies, it is

important that researchers are ‘particularly attentive’ to their design

choices ‘to ensure that instruments are presented and delivered in a

uniform, yet usable manner’ (p217). However, the same is true of paper

surveys, with the design aiming to prevent errors occurring through faults

in layout and question routing. As such, careful attention was paid to

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ensuring that the layout of both formats of the questionnaire was as

straightforward as possible.

4.53 Respondent numbers

Using the snowball sampling method and being reliant upon colleagues to

pass on the email link, and on volunteers to take part in the research, it was

not possible to predict the number of likely respondents that would be

recruited. With the sampling frame being wide-ranging (practicing or

academic staff in England) it seemed likely that the survey might achieve a

healthy number of responses, and it was hoped that the survey would

achieve at least 100 respondents across a range of professions in each

phase (practicing staff and academic staff). Dates were planned at which to

review the respondents’ status (in terms of profession and seniority level).

In the event, in phase 1a the survey had achieved over 200 responses at the

review date. However, it was noticeable that some professions were more

heavily represented than others, with some professions represented by

over 20 respondents and some represented by less than 5. At this point the

use of adverts on online forums became relatively strategic, with links to

the study only placed on forums targeting specific professions who were

less-well represented in the responses. This was a practical (and

beneficial) approach, as it was a time-consuming and at times frustrating

task (with some forums not having administrators to request permission to

join and post a link) and there would not have been time to find forums and

try and recruit participants from all different H&SC professions. Phase 1a

ended with 290 responses, 2 of which were excluded because they were

from non-H&SC professions (1 chaplain and 1 IT consultant).

Phase 1b, with academic staff, was conducted in exactly the same way, with

email and paper options for the survey. Despite repeated attempts at

recruitment, and asking a growing number of colleagues to forward the

survey, this phase ended with only 31 responses after ten months of

attempted data collection (1 of which was excluded as it was completed by

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a chaplain). The full distribution of survey respondents upon which the

analysis is based is shown in Table 4.1.

Table 4.1 Professional background of survey respondents

NHS / Practicing Staff Academic

Audiologist 1 -

Dentist 3 -

Dietician 1 1

Doctor 92 3

Health visitor 3 -

Midwife 20 1

Nurse 35 11

Occupational therapist 21 7

Pharmacist 8 -

Physiologist - 1

Physiotherapist 30 3

Podiatrist - 1

Social worker 18 4

Speech and language

therapist 56

-

Vision impairment

rehabilitation -

1

While respondents from the practice side can be seen to represent a broad

range of professions, the resulting limitation of having only a small number

of academic respondents is that the results cannot be compared across

professions for the academics, and it is only the views of two professions

(nursing and occupational therapy) which are really represented in those

results.

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4.6 Interviews

As I have argued in Chapter Two, identity, professional identity and

education are all perceived and experienced differently by individuals, and

as such exploration of this topic required a methodology that allowed the

researcher to explore these issues with individuals. To explore perceptions

of interprofessional education and professional identity in depth, I

conducted a series of semi-structured interviews with both practicing and

academic staff.

The interview schedule consisted of a list of open-ended questions (and

follow-up prompts if they appeared relevant), to allow for exploration of

key themes led by participant’s own priorities and perceptions. Of the four

philosophical approaches to qualitative research interviewing outlined by

Kvale (1996), my own approach resembles most closely the

phenomenological in that it involves an:

…openness to the experiences of the subjects, a primacy of precise

descriptions, attempts to bracket foreknowledge and a search for

invariant essential meaning in the descriptions. (p38)

Fontana, following Dingwall (1997) suggests that from a

phenomenologically informed perspective:

…individuals in interviews provide organizing accounts; that is,

they turn the helter-skelter, fragmented process of everyday life

into coherent explanations, thus co-creating a situationally

cohesive sense of reality. (Fontana 2001, p166)

Taking this phenomenological approach, ‘describing the world as

experienced by the subjects, and with the assumption that important

reality is what people perceive it to be’ (Kvale 1996, p52), respondents

were allowed to take the interviews in a direction they wished, and so the

interview structure was not always stuck to rigidly. The result was that

while most of the topics on the interview schedule were usually addressed

at some point during the interview, they were not always addressed in the

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same order. As Holstein and Gubrium (1995) note, the ability to be

relatively flexible is important in an ‘active interview’ so that the:

…respondent’s positional, linkages and horizons of meaning take

precedence over…the predesignated questions that the interviews

is prepared to ask. (pp76–77)

Holstein and Gubrium go on to state that such an approach allows the

‘responses to determine whether particular questions are necessary’ which

they suggest results in an ‘improvisational, yet focused, quality to the

interview’ which is important for the meaning-making process of the

conversation (1995, p77). Thus utilising such an approach is not

necessarily problematic in that it is viewed to highlight the priorities of the

respondent rather than being led by the research questions. As most of the

topics were covered in all interviews, and transcripts were transcribed

verbatim and could be reflected on in the analysis, I believed that such an

approach was beneficial to the quality of the data collected rather than

detrimental in any way.

Due to requirements of the ethical approval, recruitment of interview

participants was achieved by asking people to give personal details at the

end of the survey, or through pre-existing contacts. Most of the

interviewees who were practicing staff were recruited through them

providing their details at the end of the survey. However, when ten

interviews had been completed it became apparent that the majority of my

volunteers were senior level staff. Yet during the interviews, many of the

respondents would make comments such as ‘I may have felt differently

about this earlier in my career’. As a result it became desirable to interview

some professionals who were not as established in their careers to see if

their views were any different. Additional emails were then sent to

contacts asking specifically for volunteers for interview who were within

three years of graduating from their course, which yielded five respondents

who fitted the criteria.

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Due to the low number of responses to the survey with academics (and

therefore lack of volunteers recruited via this method), and because a

further purpose of interviews with academics was to contribute to the case

study work (see Section 4.7), most of the academic interview respondents

to take part in the study were personally approached and invited to take

part, having previously been involved in the ALPS CETL. This meant that I

already knew the majority of the academic interviewees but had not

previously met any of the practicing staff who were interviewed. However,

the interviews were carried out in the same way for all respondents (at a

time and location convenient to the respondent, usually at the University of

Leeds or in their workplace) and no questions were excluded from the

interview even when I had met the respondents previously and may have

‘known’ the answers (how they became involved in the ALPS CETL for

example). While knowing some of the research participants could lead to a

critique of ‘objectivity’, I would suggest, following Hamersley and Gomm

(1997), that ‘all accounts of the world are…constructed on the basis of

particular assumptions and purposes’ (p5) and that as such, there is no

such thing as an ‘objective’ perspective. As Denscombe writes:

Each researcher produces an account of a social phenomenon

which is unique to himself or herself and each account stands in its

own right as a statement about that phenomenon – no better and

no worse than others – just different. (2010, p89)

From this perspective, regardless of whether I knew any of the

respondents, I would still end up with my personal and unique

interpretation of the data. The fact that I did know some of them is then

important contextual information that is recognised and reflected upon

where relevant in the analysis.

There is a body of work on ‘interviewing experts’ which needs to be

acknowledged here, as both practicing H&SC staff and academics fall into

the category of ‘professionals’ who have acquired a ‘canonized special

knowledge asset via an institutionally specialized and…formalized training’

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(Pfadenhauer 2009, p88). However, I was not seeking to interview them in

their capacity of holders of professional knowledge per se; it was rather to

interview them as individuals about their experiences of being

professionals. As such, the methodological texts written on this field are

not particularly relevant, as they focus mainly on the difficulties of

interviewing when there is a power imbalance, or on the challenges

associated with gaining information from ‘elites’, neither of which was

relevant in this instance. I did, however, always introduce myself by

acknowledging that I had a background in sociology as opposed to H&SC, to

ensure that, while dealing with questions about perceptions of their own

profession and other professions, respondents did not view me as a

‘potential critic’ (Bognor and Menz 2009).

Kvale and Brinkmann (2009) note that different interviews have different

purposes, and as such there are different forms that interviews may take.

However, the purpose of undertaking interviews in this instance cuts

across their proposed typologies, being in part ‘conceptual’, in part

‘narrative’, and to a certain extent being grounded in a ‘discursive’

background (Kvale and Brinkmann 2009, pp151–158). In terms of

‘conceptual clarification’, one purpose of these interviews was to ‘chart the

conceptual structure’ of respondents’ conceptions of both interprofessional

education and professional identity. As is common with this type of

interview, respondents were asked to give ‘concrete descriptions’ of these

terms, and, in theory, this part of the interview data could:

…serve to uncover respondents’ discourse models…their taken-

for-granted assumptions about what is typical, normal or

appropriate.

(Gee 2005 quoted in Kvale and Brinkmann 2009 p151)

Some aspects of the interview were narrative, with the respondents being

asked to give accounts of their professional background and their

experiences of interprofessional education, as well as other ‘stories’ offered

spontaneously during the course of interviews. Again, this is a commonly

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recognised and well-trodden path when conducting interviews, with

Mishler suggesting that:

…there is a wide recognition of the special importance of narrative

as a mode through which individuals express their understanding

of events and experiences. (1986, p68)

However, Mishler also highlights that there are several implications of such

an approach, including the unavoidable nature of the interviewer becoming

coparticipant in the discourse:

Differences in whether and how an interviewer encourages,

acknowledges, facilitates, or interrupts a respondent’s flow of talk

have marked effects on the story that appears…interviewers and

interviewees are both aware of and responsive to both the

cultural and research contexts within which a particular

interview is located. (1986, p105)

Nevertheless, the narrative aspects of the interviews were useful. In

particular, the biographical aspect of asking respondents to describe their

professional background was central to exploring individuals’ perceptions

of their own professional identity. Roberts suggests that:

In the face of debates about the ‘fragmentation’ of identity or

‘multiple identities’, with discussion often more in the realms of

abstract theory rather than based on ‘lives’, the appropriateness of

the study of biography becomes ever more apparent in seeing how

identities are formed and grounded within spatial,

organizational and other structures. (2002, pp170-171)

Returning to the notion of the importance of ‘plot’ to narrative (as

discussed in Chapter Two), when analysing narrative, Propp (1975) looked

to reveal the underlying plot summaries of stories, by producing a series of

statements that summarised the main features of the story. The advantage

of this technique is that it results in a list of ‘who did what to whom in

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which order’, which includes a ‘list of characters with their spheres of

action and styles of enactment’ (Beech and Sims 2007, p294). In order to

achieve this, once the interviews had been transcribed, index cards for each

of the interview respondents were created which outlined the main ‘plot

points’ of their professional histories. Not only did this help with exploring

each individuals’ narrative of their own professional histories, they were

also useful aide memoires for remembering each participant and for

looking at their responses in context. Combining the conceptual and

narrative approaches was therefore useful for understanding as far as

possible how each respondent understood and described their own

professional role and background (narrative), and what they understood

by the term ‘professional identity’ (conceptual) and how this related this to

their opinions of IPE.

Following Potter and Wetherell (1987), Kvale and Brinkmann (2009, p156)

also suggest that while all interviews are naturally discursive, interviewers

working within a discursive framework will be attentive to issues such as

variation in responses, will use techniques which allow rather than disable

diversity, and will view interviewers as active participants rather than

‘speaking questionnaires’. Assuming aspects of this approach was

important for this study in that one of the key aims was to establish what

participants thought about IPE. To do this in the interviews, I first asked

interviewees to define what they thought professional identity was, and

then developed the conversation about professional identity regardless of

how they defined it as one of the key aspects of discourse analysis is to

‘focus on how knowledge and truth are located within discourses’ (Kvale

and Brinkmann 2009, p155). While not based on an entirely discourse-

analytic approach, using such an interview technique was important in

helping to understand how people were able to conceptualise both

professional identity and interprofessional education, and how they

thought that understanding both was an integral part of becoming a

professional.

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4.61 Interview participant numbers

16 practicing staff and 17 academic staff were interviewed (I had aimed to

interview 15 in each group). As recruitment was based upon a mixture of

those who volunteered after the survey and pre-existing contacts (for

academic staff) it was not possible to aim to interview a certain number of

respondents from any single profession. Instead, I decided to interview a

wide a range of people from as many different professions as possible, with

the aim of hearing many different ‘narratives’ about professional role and

background. The number of representatives from each profession

interviewed is indicated in Table 4.2.

Table 4.2: Current role or professional background of interview

respondents

Practicing Staff Academic Staff

Audiologist - 1

Dietician 2 1 Medic 4 2

Midwife 1 * 1 * Nurse 2 5 *

Occupational Therapist 2 2

Pharmacist 2 - Physiotherapist 1 * 1

Radiographer - 1 Speech and Language Therapist 2 -

Social Worker - 2 Vision impairment rehabilitation - 1

* Denotes that at least one respondent classified under different professional role or background indicated that they also trained and worked for the indicated profession for a period of time.

4.7 The ALPS CETL Case Study

In addition to literature reviews, surveys and interviews, this research is

also partly based upon a case study of the Assessment and Learning in

Practice Settings Centre for Excellence in Teaching and Learning (ALPS

CETL). The data collection for the case study involved specific questions

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included in interviews to ALPS participants (the majority of academic staff

interviewed) and some analysis of key ALPS documents such as planning

materials and reports, to look for evidence of issues and successes arising

from attempts to introduce interprofessional assessments through inter-

and multiprofessional working. This introduces a further methodological

dimension to the study in the form of what Webb et al. (1966) call

‘unobtrusive methods’. This refers to ‘data gathered by means that do not

involve direct elicitation of information from research subjects’ (Lee 2000,

p1). In theory, such sources can be advantageous as it removes ‘impression

management’ (such as the tendency to over-report socially ‘desirable’

behaviours) by respondents in interviews and surveys, which can

potentially distort data (Webb et al. 1966; Bradburn et al. 1979; Lee 2000).

However, it should also be noted that documents themselves are recorded

for a purpose. For example, some of the reports published by the ALPS

CETL were written at the request of their funders to show what progress

had been made in implementing the programme, thus they do not present

in detail any discussions and negotiations that occurred between different

programme partners. In essence, they are a ‘cleaned’ version of events that

project partners were happy to leave as a public record of events, and so

even this data needs to be used with a certain amount of reflexivity.

Consideration was given to undertaking some content analysis on the ALPS

documents, which in its simplest form consists of computer-assisted

techniques to generate word counts, although the wider definition of the

methodology concerns reducing ‘freely occurring text to a much

smaller…representation of its meaning’ (Marshall 2008, p114). However

an initial reading of ALPS documents indicated that this might be

problematic in that some key words of interest had multiple meanings;

while there seemed to be some difference applied to the use of the terms

‘interprofessional’ and ‘multiprofessional’ (although the distinction was not

always explicitly made), the concept of ‘collaboration’ was applied to

multiple scenarios, being relevant to cross-HEI, cross-profession and cross-

agency working. To count instances of the word ‘collaboration’ in the

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documents would therefore have been potentially meaningless in this

context, as this thesis is less concerned with the cross-HEI partnerships to

which the term might be referring. Coupled with the fact that there was no

certainty that the terms ‘interprofessional’ and ‘multiprofessional’ were

used in a consistent manner, it was more significant for the purposes of this

study to concentrate on reading the documents with reference to the

context in which they were written, giving consideration to both who

authored the papers and who the intended primary audience for them was.

Case study methodology can involve both multi- and single-case studies

(Yin 2009; Bryman 1988), but in this instance, a single-case design has

been used. This follows the rationale for a single case study design where

the case represents an extreme or unique case (other rationales may

include a single case study as a critical case against which to test a theory,

or as a representative or typical case) (Bryman 1988; p47). Silverman also

highlights that:

Purposive sampling allows us to choose a case because it

illustrates some feature or process in which we are interested.

However…[it] demands that we think critically about the

parameters of the population we are studying and choose our

sample case carefully on this basis. (2010, p141)

ALPS was atypical in terms of its size and consequent ambition for a

multiprofessional / interprofessional programme of work. ALPS included

16 H&SC professions in both the design and delivery of assessment and

learning in practice settings, and as such potentially offers up experiences

of this multiprofessional and interprofessional working that smaller scale

studies are not able to. Issues around negotiations of language, large-scale

decision making and organisational practicalities are all key issues which

will increase difficulties for IPE teams in relation to the number of

professions involved. As such, using ALPS as a case study may present

some findings that case studies exploring other smaller scale initiatives

may take longer to encounter. Nevertheless, there are other larger scale IPE

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programmes that are useful for comparison: the Common Learning

Programme (CLP), for example, which involved students from the

Universities of Newcastle, Northumbria and Teesside in partnership with

two local Workforce Development Confederations. Evaluation reports and

other published findings from such projects have been used to

contextualise the case study work.

Much of the (large quantity of) existing work on case studies concentrates

on debates around the generalisability of case study data (Silverman 2010;

Yin 2009; Blaikie 2000; Donmoyer 2000). However, Gilbert (2008)

acknowledges that for case study research ‘there is [usually] no attempt to

select a random or a representative sample of cases’ (2008, p36). Indeed,

in this instance, the purpose of using a case study is not to extrapolate the

results to claim that the experience of the ALPS programme is

representative of other multi- or interprofessional initiatives. Rather,

talking about ALPS in the interviews was useful for exploring participants’

perceptions of the processes involved in introducing a multi- or

interprofessional programme, and their perceptions of the impact of

working on such a programme. The advantage of using the ALPS CETL

programme to do this was having worked for the ALPS CETL, I was very

familiar with the initiative, the context of the programme and some

decisions made within it. It must therefore be acknowledged that one of

the primary reasons for selecting ALPS as a case study was that I was

confident that I could build up a comprehensive picture of the programme

for a case study, as well as gain access to key documents and interview

participants. Clearly, this situation does have potential implications for

data collection and analysis, but Denscombe (2010) highlights that it is

usual for social researchers to be involved in research in which ‘they have a

personal interest’ (p28). Indeed, from my intrepretivist standpoint, I

would argue that my position as a researcher is an ‘inescapable factor’ in

any social research, and that a reflexive approach around my own position

and background would be an important part of the analysis regardless of

whether or not I had been employed by the subject of the case study

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(Denscombe 2010; Finlay 2002). As such, I do not view my position as

overly problematic, but do acknowledge the need to explain how I was

involved and when. While I was employed in the ALPS CETL when I started

this research, by the time I came to plan and undertake the interviews,

neither the CETL nor the extension project (in which I was not involved)

were still active. This afforded me the fortunate position of looking at the

CETL and its impact as an ‘insider’ for the original part of the programme

but as an ‘outsider’ for the latter part of its work. Additionally, the case

study is only a small element of this research; it was included in the study

because it was both interesting and relevant for the topic at hand, and as a

larger scale interprofessional initiative, it was worthy of study for this

research regardless of my involvement.

4.8 Analysis

The approach adopted for analysis can be loosely described as a ‘grounded

phenomenological interpretivist’ approach, which is to say that the analysis

is as grounded in the data as possible; is phenomenological in that it is

‘primarily open-ended…searching for the themes of meaning in

participants’ lives’ (see Rossman and Rallis 2003, p276); and is

interpretivist in that it seeks to find the meanings that underscore people’s

opinions about their professional identity and IPE. However, I remain

mindful of a presentation given by Zukas (2012) who suggested that

researchers can spend too much time and effort defining their analytic

standpoint, often to the detriment of their study. While it is important to

acknowledge this approach has been taken (as opposed to seeking to prove

a hypotheses or to create an ethnography of H&SC professions) I have

already highlighted that, from the perspective of there not being such a

thing as ‘objectivity’ (see section 4.6), the analysis can only result in a

unique interpretation of data, whichever approach is taken. However, the

analysis did involve a number of standard elements of research work to

achieve the most grounded scrutiny of data possible, and this is described

below.

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As the majority of the variables explored in the survey were categorical, the

main analysis of data was carried out using non-parametric statistics to

explore relationships between the variables. In particular, the independent

variables of ‘profession’, ‘stage of career’, and ‘prior experience of IPE’ were

explored with reference to a number of other variables, including opinions

of IPE and attitude towards working with other professions. Exploring the

relationships between different variables has been done through the use of

cross-tabulations to examine percentage differences, and where relevant,

the strength of apparent relationships have been tested using the Pearson’s

Chi-square and Cramer’s V statistical measures. Chi-square (χ2) is a test

specifically designed for use with categorical variables and determines if

there is a discrepancy between observed values and the expected values if

data is distributed proportionately (Walker and Almond 2010). The

resulting calculation indicates the likelihood with which it is possible to

reject the null hypothesis that there is no relationship between the

variables being explored. In order to interpret the results of the test and

establish the extent to which a χ2 value may be considered significant, a

distribution table is required; for the results described in this thesis a table

produced in SYSTAT’s Data Basic and published in Wright (2002, p138)

was used.

Cramer’s V can be used on a variety of variables (binary, nominal or ordinal

scales, or any combination of the two) and can be used on any size of table

(Kent 2001). Importantly for this study, it also does not revert to zero

when one or more cells of a table is empty, which sometimes occurs in the

data set used here. For the Cramer’s V results, V = 0 shows that there is no

association between the variables and V = 1 indicates that there is unity or

complete association between the variables explored.

As with all statistical tests, there are acknowledged limitations associated

with the use of both Chi-square and Cramer’s V. For Chi-square when the

numbers in tables are small the approximation of expected results is poor

(Campbell and Swinscow 2009), and with larger data sets, small variations

can produce results that are ‘significant’. Similarly for Cramer’s V there is a

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reliance on calculating Chi-Square, which itself assumes large values (Kent

2001). To ensure the statistics are not misused, it is generally understood

that they should only be calculated when ‘fewer than 20 per cent of all cells

have expected frequencies of less than five’ as well as ‘that no cell has as

expected frequency has less than one’ (Kent 2001, p112). This rule has

therefore been applied in the analysis undertaken here. Despite these

limitations, these tests are useful tools in establishing whether results are

likely to be significant (that is, would not have occurred if the null

hypothesis were true). Cramer’s V is also useful from the perspective that

it makes no distinction between independent and dependent variables,

which is particularly useful in this research where it may not be possible to

claim that opinions on one element (such as professional identity) are

dependent upon experiences of another (such as IPE) given the individual

nature of such experiences, but where it might be useful to establish if

there is any apparent association between the two. This analysis was used

to explore whether there was any apparent relationship between

profession, stage of career, prior exposure, or involvement in, IPE

initiatives and opinions about IPE and interprofessional working. The

open-ended questions were coded as per the qualitative data (see below).

This was subsequently used to describe whether there were any themes

relating to how people describe their professional identity, which in part

informed some of the questions used in the interviews.

The interview analysis started with notes that were taken during each

interview, and the interviews were transcribed verbatim as soon as

possible, enabling what Rossman and Rallis (2003, p271) describe as

‘learning as you go’. Interview transcripts were annotated with immediate

thoughts while transcribing, with the latest transcriptions and notes re-

visited before conducting a further interview. The coding was undertaken

manually, through reading and re-reading the data, and by writing notes

and suggested code headings on to interview transcripts. This inductive

approach is better suited to explorative inquiry and allows for themes to

emerge from the data, in contrast to attempting to fit these into a pre-

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existing coding frame built upon the preconceptions of the researcher

(Braun and Clarke 2006). Individual sheets of paper were then created for

each code and relevant quotes related were recorded on them, sometimes

creating 8 – 9 sides of quotes per code. Codes were created for phrases,

statements or narrative that recurred between interviews or specifically

addressed one or more of the research questions (Koh et al. 2014). Sub-

codes were created for minority opinions or for opinions that differed from

the majority of opinions expressed. While doing this manually was

relatively time-consuming, this method was the most convenient for

making the best use of time to undertake the analysis. While computer

programmes such as nVivo and Dedoose were both explored as

possibilities for use in coding, the manual process including writing out

relevant quotes meant that familiarity with the data and available quotes

was achieved in a way which seemed less likely had a computer

programme been used.

The analysis itself was thematic, for both the narrative elements and open-

ended responses to questions in the interviews and surveys. As just one of

a number of recognised methodologies of analysing narrative data (see

Riessman 2008), this seemed the most appropriate way to deal with both

the volume of data and the fact that interviews contained a mixture of

narrative and descriptive responses. Where the theming of narrative

involves coding ‘sequences’ of responses rather than ‘segments’ (as is

usually done in thematic analysis of qualitative data), the process was

relatively similar (Riessman 2008, p74). Having had no previous

experience of working with narrative data this was also the method that

was the most straightforward to attempt. Thematic analysis of narrative is

acknowledged for the limitation that readers must assume that everyone in

a cluster means the same thing in their statements, which has the potential

to obscure ‘meanings-in-context’ (Riessman 2008, p76) although the same

limitation must be acknowledged for the theming of any qualitative data.

Ultimately this method was used because it allowed for the discussion of

the results to be as grounded in the data as possible.

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Case studies themselves are a form of analysis, intended to ‘capture the

complexity’ of (in this instance) a particular programme of work: the ALPS

CETL (see Rossman and Ross 2003, p278). The case study of ALPS was

particularly focused on establishing how a large scale multi-professional

programme of work was introduced and established, how the concepts of

IPE and interprofessional assessment were introduced into curricula and in

practice what decisions were taken, and what influential events occurred

along the way. Texts from the ALPS CETL and relevant interviews

undertaken for this research (i.e. with staff members involved in ALPS)

were therefore read and coded, being context-driven by this set of

questions (rather than data-driven).

This chapter has described the methods and phases of data collection used

to collect the data for the research presented in the following chapters. It

has described the importance to the research of staff opinion, and has

outlined some issues associated used with the chosen methodologies of

questionnaires, interviews and case studies. As with all interpretive

research it is acknowledged that the researcher’s position of investigating a

given topic places on it an emphasis which may not have otherwise have

had for the respondents. Nevertheless in order to advance understanding

of conceptualisations of professional identity and interprofessional

education, the methods chosen have been justified here as the most

appropriate to do so. The following chapter introduces the work of the

ALPS CETL in detail, and describes the results of the case study.

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Chapter Five

Exploring the impact of a large-scale interprofessional

programme of work.

Case study: The ALPS CETL

5.1 Introduction

This chapter uses the Assessment and Learning in Practice Setting (ALPS)

Centre of Excellence in Teaching and Learning (CETL) as a case study,

exploring longer-term impact on both the curricula and staff of institutions

taking part in a large scale multi- and interprofessional programme of

work. More specifically, this chapter seeks to address the following

question:

What impact does the implementation of a large-scale interprofessional

programme have on staff involved in delivering the programme?

To do this, the ALPS programme and its aims are described in detail. Using

evidence from programme documents (evaluation and research reports;

the website / documents published via the website) and interviews,

attention is paid to how the project was implemented across programme

partners, including consideration of recorded barriers and successes.

Themes drawn from interview data are also used to examine the perceived

impact of the ALPS CETL programme on both the staff and institutions

involved, including staff who participated in its delivery and

implementation.

5.2 The ALPS CETL

ALPS was one of 74 CETLS funded by HEFCE (the Higher Education

Funding Council for England) after a successful bidding process in 2004.

The original ALPS partnership was initially funded as a five-year

programme, running from 2005 to 2010, but the partnership was awarded

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further funding by the (then) Yorkshire and Humber Strategic Health

Authority (YHSHA) and subsequently funded for a further 12 months (to

2011).

ALPS was a regional consortium of five West Yorkshire-based Higher

Education Institutions (HEIs), consisting of the Universities of Leeds,

Huddersfield, Bradford, Leeds Metropolitan and York St John (York St John

College at the time of initial bidding). These five HEIs were collectively

responsible for delivering courses which covered sixteen different H&SC

professions. The ALPS collaboration was thus unique in size and structure;

in terms of partner numbers, it was the second largest CETL, and involved

the largest number of professions of any of the CETLs. The CETL

programme had two main aims; to reward excellence in teaching practice,

and to invest in that practice, bringing further benefits to students, teachers

and institutions (HEFCE Website).

The overarching rationale for the ALPS CETL was:

…to ensure that students graduating from courses in H&SC are

fully equipped to perform confidently and competently at the

start of their professional careers.

(ALPS 2004 p2, original emphasis)

Based on the notion that students value accurate and fair assessment

processes which provide both effective feedback and a basis for reflection,

the original ALPS bid suggested that its overarching aim would be achieved

through the development of a series of work-based assessments. These

assessments would measure, both formatively and summatively, a series of

core competences which would inform students’ portfolios of evidence,

with feedback provided from peers, tutors, patients and self-reflection.

Ambitiously, it was claimed that ALPS would:

…permanently change the culture of the organisations

involved, in line with relevant strategic changes in workforce

planning and the delivery of patient care (stemming from the NHS

Plan, DH 2000). (ALPS 2004, p2)

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To achieve this, it was suggested that the CETL would bring together

‘uniprofessional expertise in workplace H&SC assessment’ which would

then be disseminated via good practice ‘within and across the institutions’.

The multiprofessional element of ALPS involved bringing together experts

from different professions to strengthen H&SC assessment frameworks

which, it was proposed, would drive learning. It was hoped this would

bring about benefits for institutions through sharing of knowledge and

resources;

By looking for commonality of purpose across H&SC education and

sharing scarce resources to assess common outcomes, we can

provide a more robust framework for the assessment of clinical

competence and use this assessment to drive strategic learning.

(ALPS 2004, p3)

Additionally, ALPS aimed to introduce or improve interprofessional

teaching and learning across all partner cohorts, while improving students’

understanding of, and competence to undertake, interprofessional working.

This included the proposal that such skills would be assessed. It was hoped

that improvements in assessment would provide ‘more opportunities for

interprofessional learning’ in practice settings with peers, and it was

proposed that as a result of the ALPS programme:

Students will benefit from interprofessional and multiprofessional

teaching to support their practice-based learning experience,

providing a range of different professional perspectives on patient

/ client care. (ALPS 2004, p21)

Furthermore, it was suggested that increased attention on

interprofessional working and learning would result in benefits for staff

involved in delivering the ALPS programme:

By undertaking assessments interprofessionally, staff who

currently act as uniprofessional role models for students will be

encouraged to reflect on their pedagogic approaches and this

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will enhance their own interprofessional patient focussed

practice.

The improved support and clarity of purpose for clinical

educators will better prepare them to cope with the conflicting

demands of workforce development and service delivery.

(ALPS 2004, p21)

Thus the aims of ALPS relating to both interprofessional learning and

working were relatively broad and ambitious, consistent with the size and

scale of the programme.

5.21 The ALPS programme of work

To meet the proposed objectives, the ALPS programme of work involved a

number of strands for developing interprofessional learning and

assessment. The main focus was the development of three ‘maps’ of

essential competences for all H&SC professions: communication, team

working, and ethical practice. The mapping process was achieved through a

number of stages: agreeing a structure for each competence; developing

statements which described each competence and splitting these into

themes and ‘hierarchies’; and developing performance criteria which

related to each statement (Holt et al. 2010).

The overarching context of this mapping process was that these

performance criteria would ultimately form the content of

common assessment tools for inter-professional learning.

(Holt et al. 2010, p266)

When each map was drafted, it was subjected to an extensive consultation

process which involved ALPS stakeholders at every level, including

Professional, Statutory and Regulatory Bodies (PSRBs), service users and

carers, academic staff, and representatives from practice (usually Practice

Learning Facilitators) (Holt et al. 2010).

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The completed maps were used as both standalone resources to be used

with and by students to develop understanding of the competences, and as

as the basis for five interprofessional assessment tools, which were

developed as workplace-based assessments (WBAs). While there are a

range of WBA tools in widespread use (Fuller et al. 2009), the language and

conceptualisation of assessments carried out in the workplace as ‘WBAs’, as

well as literature exploring their use, has been informed by medicine (see

Kogan and Holmboe 2013). However, within ALPS, the language of ‘WBAs’

was accepted and there was a recognition of advantages in their use which

would apply equally to all ALPS professions. If used effectively, WBAs are

formative assessments which aid student learning by identifying learning

needs via feedback, while also allowing faculty to ‘track student attainment’

(Fuller et al. 2009, p368). The WBAs developed for ALPS were not based

on any existing tool and were designed to be used in ‘generic practice

scenarios’ (Dearnley et al. 2013, p437), with the intention that they would

be used by all H&SC professions. The five scenarios were:

Demonstrating respect for a service user during an interaction

Gaining consent

Knowing when to consult or refer

Providing information to a colleague

Working interprofessionally

(Dearnley et al. 2013)

Each tool was developed with the same format and all had a mixture of

Likert scale ratings, multiple-choice questions and open-response sections

which allowed for more detailed feedback. The tools were divided into

segments, allowing students to collect feedback from a variety of sources:

practice assessors (from their own profession), an interprofessional

assessor (a qualified member of staff from a profession other than their

own), and peers (students). Norcini and Burch (2007) have identified that

WBAs can be ineffective when there is poor quality feedback from

assessors, or where there is no clear link established between an

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assessment and a learning outcome. The ALPS assessment tools attempted

to address such concerns by providing space for students to reflect on

feedback they received and the capacity to develop an action plan based on

this (if required) which could be signed off by a practice educator.

To support the student assessments, a ‘large scale mobile technology’

programme was also introduced in order to ‘enhance student work-based

learning’ (Davies et al. 2010, p8). The purpose of developing resources to

be used on mobile devices (phones) was allowing students to gather

instant feedback on assessments while on placement which would

contribute to an electronic record (e-portfolio) of their work and progress.

Capturing this data electronically also meant that tutors in universities

could log in to the e-portfolio system, or be notified instantly, of results of

placement assessments. The advantage of this process was that students

could access support from their university-based tutors while still in

placement settings, where previously they could not do so without

returning to their institution. However, given the number of students

involved in ALPS across all five partner HEIs (c.9,000 per year) and the

number of mobile devices purchased to support the programme (900), the

ALPS tools were ultimately developed for use on both mobile devices and

on paper, ensuring that those students who were not allocated a device

were still offered an opportunity to use the tool and gain more feedback

while on placements.

5.22 ALPS programme implementation

The ALPS programme of work was undertaken and implemented by a

series of management and working groups, whose membership varied

depending on expertise, but was made up of representatives from all five

ALPS partner HEIs, members of the SHA (where appropriate), and

members of the ALPS Core Team (the central full-time team who supported

the running of the ALPS CETL, the structure of which is outlined in

Appendix 8). Table 5.1 outlines the different working and management

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groups responsible for delivering proposed work in the ALPS programme,

as well as their function (a diagram of group structure can be found in

Appendix 9). In addition to the working and management groups, each of

the ALPS partner HEIs had a ‘Partner Site Implementation Group’ (PSIG)

responsible for acting on decisions taken by the working groups in order to

implement the ALPS programme at their own HEI.

5.23 Context

While other large-scale interprofessional programmes exist (for example,

the Aberdeen Interprofessional Health and Social Care Initiative or the

Interprofessional Training Wards at the Karolinska Instituetet), the scale of

ALPS in terms of number of institutional partners (five), the number of

professions involved (16), and the number of students potentially involved

per year (9,000), meant that the ALPS programme was an interesting case

study for this thesis because of its relatively unique size. However, the

context of the programme was also unique and must be given

consideration before attention is turned to its outcomes.

As has been made clear in Section 5.21, while a large portion of the work

(such as the competency mapping and development of generic assessment

tools) contributed to the improvement of interprofessional education and

working, the ALPS programme had a number of aims relating to other

educational developments. Thus, unlike other large-scale interprofessional

initiatives, improved interprofessional outcomes were not the only focus of

the programme. Additionally, as a CETL, ALPS held an unusual status for

an academic programme of work. CETLs were funded based on recognition

for existing excellence in teaching and learning, acknowledging that

existing reward systems within HEIs were more likely to reward excellence

in research than in teaching (SQW 2011).

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Table 5.1: ALPS Management and Working Groups and their function

Group Function Advisory Board Senior management group, responsible for overseeing strategic direction of ALPS, financial planning and monitoring of all other

management groups and embedding strategic and operational activities of all parties. Baseline, Outcomes and Research

Group tasked with carrying out specific research – namely, to identify and develop mechanisms for measurement of validity and reliability of practice-based assessments.

Common Competence Mapping

Group that defined ‘common competency mapping tool’, ‘common assessment tool’, and mapped out requirements for these by developing a shared, agreed understanding and definition of common areas (communication, team working, ethical practice).

Dissemination and Impact

Responsible for Dissemination & Impact Strategy; helped to identify a network of influential individuals and organisations to ensure they were aware of ALPS and its activities and built links with the Higher Education Academy and other CETLs.

e-Valuation A sub-group of both the IT and Research Management groups, this group was responsible for delivering the research and evaluation of all e-learning elements of the ALPS programme.

IT Group Group responsible for leading the technical elements of the ALPS programme and for implementing the mobile technology and supporting structures in each of the ALPS partner sites.

Joint Management Main management group attended by all ALPS partner leads and chairs of all groups. Responsible for overseeing financial management and project plans, and facilitating communication between all ALPS partners and groups.

Monitoring and Evaluation

Group tasked with establishing the standards and quality against which ALPS milestones and objectives were measured. Responsible for wide ranging evaluation of ALPS activities including effects on areas such as capacity building, value for money, cost effectiveness and communicating feedback to ALPS students, staff and stakeholders

Research Management

Responsible for overseeing all research-related activity and ALPS research groups. Developed and implemented the ALPS research strategy, monitored research outputs and quality of outputs from all ALPS partners.

Risk Assessment Responsible for monitoring management of performance against targets; Core Team performance and identifying any issues of a strategic nature & report accordingly to the Advisory Board.

Service Users and Carers

Responsible for developing and enhancing the role of service users and carers in assessment, and learning in practice settings; advising other groups on membership in line with best practice.

Tools The remit of the Tools Group was initially to synthesise evidence and information from the ALPS Groups in order to identify a set of tools to be used in assessing common competences of health and social care students in practice using mobile technologies, and later to develop work developed by the Common Competence Group into common assessment tools.

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However, as a result of how CETLs were funded and monitored, there was

no penalty for ‘failure’ nor any evaluation framework in place at the launch

of the CETL initiative; this made outcomes difficult to measure (SQW

2011). HEFCE’s management of the CETL programme was deliberately

‘light touch’ (Saunders et al. 2008) but, in line with all other CETLs, HEFCE

did not place any requirements on any activity becoming embedded in any

of the partners’ H&SC curricula (although the extent to which it did so is

explored in Section 5.6). For ALPS however, it was hoped that by choosing

competences that were common to all professional groups involved that

the maps would become embedded within each individual curricula, with

the assessment tools as an additional option that could also be easily

assimilated into individual curricula. As a result, ALPS was slightly

different from other large scale interprofessional programmes because,

while it was hoped it would be embedded within core curricula, it was

monitored by the funders as a five-year programme that might cease once

funding ended. Consequently there was less external pressure on project

partners to embed the programme than there might otherwise have been.

Additionally, within the five partner HEIs, ALPS was also only a part of the

whole picture; most if not all professions at each ALPS partner already had

elements of IPE in their programme. The ambitious aims of ALPS to

improve interprofessional learning and working across all partners were

therefore not the only elements of IPE in which some academics were

involved.

Finally, the work of ALPS was based upon the concept of ‘interprofessional

assessment’, a term which has more commonly been used to describe the

assessment of interprofessional learning outcomes (see Morison and

Stewart 2005). The aim of the ALPS tools, however, was to enable students

to gather feedback from a variety of sources, including qualified staff from

professions other than their own, a process more accurately described as

part of gathering ‘multi-source feedback’ (MSF). Indeed, interprofessional

ALPS assessment was not a stand-alone process but incorporated into a

tool, enabling students to gather feedback from a variety of sources, and so

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was itself a form of MSF. MSF is a recognised method of assessing

performance, used by a variety of professions (including those outside

H&SC), and has been shown to provide high levels of feasibility, reliability

and validity in fields such as medicine (Donnan et al. 2014). The

‘interprofessional assessment’ developed by ALPS needs to be understood

in this context, as opposed to being viewed as a new, different, and perhaps

less-proven form of assessment.

5.3 Programme Outcomes and Evaluation

The purpose of this case study is to understand the impact of a large-scale

interprofessional programme on the staff involved in implementing it. To

address this, the processes undertaken to implement ALPS have been

described, but clearly give no indication about the extent to which

implementation was successful, nor its impact on staff. The following

section will therefore examine some of the research and evaluation

documents produced by ALPS in order to explore how successful

implementation of the programme appears to have been. At this juncture it

may be useful to note that in the initial round of CETL applications there

was no mention of research requirements, with the implication that

research would not be funded by the programme. This stance was

somewhat softened in the second round applications although there was no

systematic emphasis on research or evaluation within the CETL

programmes. The extent to which each CETL ended up with planned

research and evaluation outputs therefore depended somewhat on their

interpretation of what would be ‘allowed’ at this second stage.

The ALPS programme did make some investment in evaluating ‘softer’

outcomes of the programme, by commissioning The ROI Academy to

undertake a Cost Benefit Analysis (CBA) of the assessment and learning

approaches which arose from ALPS (ALPS and The ROI Academy 2010). At

the time of the report (2010) the conclusion from the CBA was that ALPS

had produced a higher than expected return on investment of

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approximately 50% of the original investment, with ‘the greatest return’ at

that stage being:

the human capital asset base of expertise in collaborative,

interdisciplinary and interprofessional working skills and

expertise in mobile, e-learning and development of shared

services. (ALPS and The ROI Academy 2010, p2)

In addition to the results showing an impact on creating value through

increased staff knowledge, they also indicated that there was ‘substantial

potential to create value for students (and hence employers) on wider

deployment’ (ALPS and The ROI Academy 2010, p3). Unfortunately the

timing of the CBA was such that it is not possible to state whether ALPS met

this predicted potential, but it is interesting to note that the increase

interprofessional skills was highlighted as being an area of great return.

The CETLs were asked to produce evaluations of their work at two stages.

The first, an interim evaluation report was produced in July 2007, and the

final summative evaluation in 2010. In addition to the self-evaluation

produced by the CETLs at each phase, HEFCE commissioned simultaneous

independent reviews of the CETL programme. However, these were not

evaluations of each CETL, rather summaries and evaluations of activities of

the whole CETL programme. At the mid-point, this evaluation included

evidence gathered from: interviews and visits to 36 of the 74 CETLs, key

informant interviews, a survey of CETL Directors, and an overview of the

CETL self-evaluation reports (Saunders et al. 2008). The final summative

report, which was completed in three months, was primarily based on the

final-evaluation reports produced by the CETLs (SQW 2011). It must

therefore be recognised that much of the evaluation material was produced

by the CETLs and could be construed as a non-impartial evaluation of the

programme, especially as there was a clear need for CETLs to ensure that

funders received the best possible impression of their work. King (2010)

noted that the self-evaluation methodology, coupled with a lack of both a

pre-arranged evaluation framework or agreed interpretation of ‘impact’,

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was also problematic for CETLs at the midpoint evaluation, where CETL

teams were to identify only able ‘limited impact’ of their programmes

(p44). Documents drawn upon here for evidence must be viewed in this

context.

The interim report produced by ALPS was based upon evidence from case

studies of activity written by both ALPS partner HEIs and working groups,

as well as the annual reports either written for, or by, ALPS management

groups. The report noted that the first phase of ALPS activity, planned to

span the first three years (2005–2008), was intended to be the ‘descriptive

and developmental’ period of the programme, concentrating on:

…mapping the competences, developing and piloting tools…[and]

engaging with practice staff, students, service users and carers.

(ALPS 2007, p7)

Two further proposed (overlapping) stages were the ‘transformative’

phase 2 in years 3 – 5, and the ‘evaluating and embedding’ phase 3,

envisaged to take place from year three onwards. Therefore the interim

report could discuss in detail only the developmental phase of the

programme. Accordingly, it was reported that much of the work up until

that point had been concerned with ‘establishing the collaborative

arrangements across the five universities and NHS partners’, as well as

starting agreed work plans (ALPS 2007, p7). The report highlights that, in

terms of collaboration (which involved both cross-institutions and cross-

professional working), ALPS was based upon an ‘ambitious model’:

…aiming as it does to change practice whilst collaborating across

Five Higher Education Institution [sic] and involving health and

social care partners. (ALPS 2007, p30)

Nevertheless, it was also reported that as a result of ALPS there had been

‘increased collaboration’, resulting in:

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…more sustainable joint working and the spreading of good

practice and innovations in learning and teaching across the

partners. (ALPS 2007, p30)

The evidence included reports from partner sites suggesting that

individuals who had previously worked predominantly inside their own

professional ‘silos’ were beginning to ‘look and be aware of good practice in

other professions’ (ALPS 2007, p21). It was also reported that the ALPS

work programme had led to opportunities for senior staff from different

professions in the same institutions to come together and share expertise

when they ‘would not normally work together’ (ALPS 2007, p19). While it

was acknowledged that it had taken time to build respect and trust

between colleagues, the positive outcomes included people attending ALPS

groups due to a ‘genuine interest in collaborative discussion regarding

practice’, as well as colleagues drawing examples from different

professions (for the first time) when looking to develop profession-specific

practice assessments (ALPS 2007, p21).

Nevertheless, the report also contains details where working

collaboratively had been a challenge for ALPS participants. With reference

to the formation of the Management Groups, for example, it was stated that:

Although it was agreed that representatives from each and every

partner to a Group were not necessary, it is probable that there

had not been enough trust established by this stage to allow some

partners to take the lead and others to take more of a back seat.

(ALPS 2007, p8).

It was also noted that:

…poor communication and lack of engagement is a major barrier

for partners with some professions less engaged than others.

(ALPS 2007, p21)

Similar issues were noted in the independent formative mid-point

evaluation of the CETL programme commissioned by HEFCE. The report

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noted that working across disciplines, faculties and departments had been

difficult for some CETL staff and that, as Universities were typically

‘compartmentalised’, there was occasionally a ‘silo’ mentality, which was

outside of the control of CETLs but did cause some considerable challenges

(Saunders et al. 2008, p71). However, none of these issues were identified

explicitly either by ALPS or by the wider evaluation as either being caused

by, or symptomatic of, interprofessional or even multi-professional

working. Nevertheless, this does not suggest that these tensions were not

due to issues relating to professional boundaries; it can only be understood

from documentation that it is possible that they were. As made clear in

Chapter 4, the fact that the ALPS CETL involved ‘collaboration’ in a number

of new ways for project partners – across profession, agency and

institution – means that these issues can only be ascribed with certainty to

new ‘collaborations’, cross-profession or otherwise.

The final summative evaluation of the entire CETL programme was, as

already highlighted, rather limited in scope, based primarily on self-

evaluation reports written by CETLS. A small amount of additional primary

research was also conducted: two e-surveys (one of Pro-Vice Chancellors,

and one of teaching and learning practitioners) and eight thematic case

studies, which again drew evidence from CETL self-evaluations, as well as

being based on further ‘selective consultations with key individuals and

organizations, where appropriate’ (SQW 2011, p2). The report focuses on

evaluating the scale and scope of the CETL programme, exploring the

impact of the CETLS on institutions involved and the wider academic

community, and on the sustainability of the programmes of work launched

by the CETL. There is little in the report of relevance for this research,

although, where relevant, it will be used to contextualise discussions

concerning the ALPS CETL evaluation.

The format of the final evaluations produced by the CETLS was prescribed

by HEFCE and very limiting in terms of the information requested. The first

section was entitled ‘statistical information’, containing information about

capital expenditure and income earned, as well as details of where staff

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would go once the CETL had ended and details of dissemination materials

(conference and journal papers). Section two was ‘evaluative reflection’,

containing twelve open-ended questions about the work of the CETL

(although each question had a word limit of 600-1,000 words). As such, the

report is of fairly limited use as a complete record of ALPS outcomes,

because the information had to be necessarily selective in order to meet the

word-limits, and was therefore probably not wholly representative of what

staff involved in the CETL would have presented at the close of the

programme. Nevertheless, the report did contain reflection on aims to

improve interprofessional collaboration and working. In response to the

question ‘reflecting on the last five years what other important messages

are there that you would want to convey about your CETL?’ the report

notes (among other things) that as a result of ALPS there was:

Impact on the reputation of the professions with their PSRBs

[Professional Statutory Regulatory Bodies]: demonstrating

leadership, innovation and interprofessional cooperation for the

good of the academic development of the professions, and thus

potential improvement in care standards

A framework for interprofessional education in practice settings

which provide a framework to meet the aims outlined by Darzi in

‘High quality care for all: NHS Next Stage Review final report’:

where ALPS has undertaken three research projects which involve

interprofessional working, learning and strategy.

(ALPS 2010, p11)

Given the report’s nature, no evidence is offered to support these

statements, which makes it problematic to assess the claims made using it

alone. However, at the end of the programme, a variety of staff wrote

reflective pieces about their experiences of being involved in ALPS. One

such piece by the ALPS Director on leadership highlights the importance of

establishing trust as vital to developing cross-profession and cross-

institutional relationships, and encourages leaders to be open to different

points of view in order to allow multi-layered projects to develop (Roberts

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2010). While again offering little in the way of a measurable outcome, such

reflections do lend support to the notion that the impact of ALPS could be

seen in the interprofessional (and cross-institutional) collaboration which

was established during the course of the ALPS programme.

Such claims gain further support from another ALPS publication which

arose from research undertaken by some of the ALPS partners in

collaboration with an external evaluation team from the University of

Birmingham. ‘Strength in Numbers’ by Hargreaves et al. (n.d.) set out to

explore ALPS’s ‘collaborative approach to innovation in professional

education’. In their study, Hargeaves et al. identified that there was

interchangeable use of the terms ‘collaboration’ and ‘interprofessional’, a

characteristic of ALPS documentation noted earlier in this thesis (see

Chapter 4):

It was self-evident from the data analysis that many of the themes

and sub themes were related to interprofessional working,

education and learning. Rather than treating this as an extra

theme, we acknowledged it as an overarching consideration for

many participants; that sometimes ‘working collaboratively’ meant

‘working interprofessionally’. (n.d., p8)

The consequence for Hargreaves et al. was that many of the themes

emerging from their research had a ‘broad consensus with much

interprofessional literature’ (n.d., p8). Although it is important to note that

it is still not possible to separate out which aspects of collaboration

(interprofessional or cross-institution) are being discussed, using

documentary analysis, individual interviews, reflective accounts and

nominal group technique (a four stage technique employed in a focus

group, involving individuals and groups identifying the most important

points of discussion they have), Hargreaves et al. identified four general

themes relating to the perceived impact of collaboration between ALPS

partners. Additionally, ‘engagement with the PSRBs’ emerged as a topic for

discussion, even though this concerned collaboration outside the ALPS

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partnerships. While participants in the study were not specifically asked

about PSRBs, Hargreaves et al. found that engagement with them was

‘unanimously seen as a successful outcome’ of ALPS (n.d., p8). In

particular, concerns that the PSRBs would be resistant to, or even block,

interprofessional assessments proposed by ALPS were not confirmed.

Although it is not possible to determine whether this attitude by PSRBs was

facilitated by the ALPS programme, the fact that lack of resistance to the

idea was established had a positive effect on ALPS partners, as it meant

they were able to develop and promote the concept of interprofessional

assessment without concern that this was against the wishes of their

professional bodies (Hargreaves et al. n.d., p9). This finding seems to lend

support to the claim made in the final ALPS evaluation report suggesting

that ALPS’ engagement with the PSRBs led to improved interprofessional

cooperation.

As made clear, the ALPS programme had a number of strands, and there

was suggestion in the report by Hargreaves et al. that some participants felt

that collaborative aspects around interprofessional / multi-professional

assessment ‘had been sacrificed to the development of the mobile

technology’ (n.d., p9). However, Hargreaves et al. suggest that this view

tended to be held by those participants less keen on technological aspects

of the programme. As with all evaluations, participants views differ

depending on personal priorities, but this highlights the potential difficulty

of interprofessional collaboration being just one aspect of a wider

programme of work aimed at those for whom it was a priority; it clearly

cannot always the primary aim / focus when other parts of a programme

have to be achieved. Hargreaves et al. suggest, however, that the result of

collaborative work of ALPS primarily resulted in an overarching theme,

with participants feeling that ‘we got further than we would have done on

our own’ (n.d., p9). This related to three further sub-themes; culture, trust,

and leadership, of which culture is particularly relevant for this discussion.

The concept of culture was, for ALPS participants, sometimes perceived as a

barrier to collaboration where:

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…defensiveness, ‘tribalism’ and shared histories about how

collaborative ventured had fared in the past all had a bearing on

the progress of ALPS. (Hargreaves et al. n.d., p10)

As discussed in Chapter Two, the complex inter-related nature of

professional histories, culture and identities is known to influence

interprofessional working (Carlisle et al. 2004; Atkins 1998), and, as a

consequence, perceptions of it. To some extent, it is unsurprising to find

concerns raised about differing ‘cultures’ causing problems for a large-scale

collaboration, and yet this was not the only finding. The ALPS participants

also noted that strong relationships began emerging where there was

perceived to be a shared ‘culture’ (defined as a ‘similar outlook’) between

professionals (Hargreaves et al. n.d., p9). This was extremely positive for

ALPS, where it led to greater participation in the programme, and as seen

in Chapter Six, this is significant for this research, where a perception of

‘shared culture’ is believed to result in more relevant and effective IPE

experiences.

One final noteworthy element from Hargreaves et al.’s report, which is

again of specific interest to this research, relates to the theme of ‘size’.

Clearly, the size of the ALPS CETL is one reason why it made a unique case

study. Indeed, whether ALPS was ‘too big’ was a question raised by

Hargreaves et al., but the authors suggest that this was difficult to answer

at ‘the distance’ from which they were evaluating the programme (n.d.,

p12). However, it was noted that:

…the plan for ALPS was wide and ambitious. Six overarching aims

led to a strategic plan that included more than a hundred

objectives. The sheer volume of work to be completed and the

complex communication systems needed to support it meant that

the progress of any one strand of work could be jeopardised or

significantly slowed down by the process of organizing meetings

and other opportunities to get work done.

(Hargreaves et al. n.d., p12)

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In Chapter Three of this research, it was highlighted that reports of many

IPE initiatives reflect upon the structural and organisational barriers that

contribute to difficulties in its implementation. It is perhaps not surprising,

but nonetheless worth noting, that a larger scale programme appears to

have encountered these difficulties in proportion to the project’s size. The

extent to which connections made between institutions and professions

were ‘natural’ or rather ‘manufactured’ as a result of the ALPS

programme’s success in bidding for funding was also queried by

Hargreaves et al., but the authors were unable to provide an answer,

concluding that, irrespective of whether the collaboration might have

occurred naturally, ALPS resulted in:

…an effective network which cuts across professional and

institutional boundaries. (n.d., p12)

The work undertaken by Hargreaves et al. has therefore provided a helpful

snapshot of a perspective of ALPS when the work and collaboration was

still funded, as well as offering further evidence for claims made in the final

ALPS report regarding outcomes of the programmes, including improved

interprofessional collaboration. This theme, and other points raised by the

Hargreaves et al. report and also discussed here, are readdressed later in

this chapter and in Chapter Six, with reference to findings of research

carried out specifically for this thesis.

5.4 Collaborative Networks extension programme

When the initial funding from HEFCE came to an end in 2010, the ALPS

CETL was awarded some continuation funding by NHS Yorkshire and the

Humber, specifically to develop, embed and disseminate the work of ALPS.

Subsequently, six collaborative networks were formed based upon the

‘shared interests and expertise’ that had developed over five years of the

ALPS programme (ALPS website). While all six networks remained, to a

greater or lesser extent, multi-professional (in that they involved any

interested parties, from whichever profession they came), the ALPS

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Common Competency and Patient Safety Network was the only one that

explicitly referenced ALPS’ ambitions to improve interprofessional

working. In fact, it is worth noting that none of the networks attempted to

take forward the use of interprofessional / generic assessment tools

developed by ALPS, focusing instead on Common Competency Maps, which

were the framework for the ALPS assessment tools. The Common

Competency and Patient Safety Network webpage stated that:

The work of ALPS is based on the hypothesis that if students

receive feedback from different sources in diverse practice

situations, then confidence, competence, assessment reliability and

interprofessional working skills will all be improved.

(ALPS Website)

This description is less detailed than the original ALPS proposals to

improve interprofessional patient-focused practice via the use of

interprofessional assessment. However, the page also stated that:

Interprofessional education is a crucial element of all health and

social care programmes and the common competency maps enable

consistent, agreed and comprehensively understood language,

which is essential for working together effectively and improving

patient safety. (ALPS Website)

Nevertheless, it proceeded to direct to the site visitors interested in further

developing IPE to an IPE programme at one of the ALPS partners, which

had existed and developed independently of all the ALPS programme.

While this is not intended to suggest that the ALPS programme had no

impact on interprofessional education, working or relationships

(perceptions of this are explored in Section 5.6), it is important to note that

the original interprofessional aspirations of ALPS were much less evident

in the Collaborative Networks than in the original bid as well as evaluations

of the original five year programme of work.

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5.5 Evaluations of other large-scale IPE programmes

As made clear throughout this thesis, the size of ALPS (and in particular the

number of professions involved) was one of the features that made it an

interesting case study, particularly as little evidence from other large scale

IPE initiatives exists. This means, however, that comparatively little other

evaluation data of larger scale initiatives is available, ruling out contrast to

the findings of this case study. It is particularly hard to find staff views of

large-scale programmes as, similar to the majority of IPE evaluations, most

published material about larger scale programme focuses on student views.

As such, the discussion that follows is based upon information on other

large scale programmes, but was not necessarily chosen because it is

directly comparable.

The ‘Common Learning’ programme (originally known as the New

Generation Project), which was conducted at the Universities of

Southampton and Portsmouth, was introduced in 2003 and now involves

around 3,500 students each year (CL Website). The New Generation Project

was one of the Common Learning Pilots – the evaluation of which was

discussed at length in Chapter Three – and, as this project has continued, it

is worthy of further discussion. Although no published evaluation of this

programme is available on the project website, a number of academic

papers about the programme were published in the early stages. A 2006

paper by O’Halloran et al. describes the process of curriculum design, with

reference to the teaching model originally developed, which had been

validated by the relevant bodies of 17 pre-qualifying programmes involved

in the project (O’Halloran et al. 2006, p25). The paper also describes the

programme’s design, which originally offered three modules with a mixture

of campus-based and placement experiences. However, this has now been

reduced to one placement-based module, which:

…provides students with an opportunity to work together on an

audit, and apply their team working and negotiation skills in an

inter-professional context. (CL Website)

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While a longitudinal study of attitudinal and knowledge change among

students was being undertaken from 2002 onwards, the extent to which

this is relevant now is questionable, given that the programme was reduced

from one module from three modules. While this reduction in modules

went against recommendations of another paper that emerged from the

programme, which suggested a need to further extend the concept of IPL

within undergraduate teaching and for post-graduate learners as well

(Humphris and Macleod Clark, n.d.), it did follow the Quality Assurance of

Basic Medical Education (QABME) report on the School of Medicine in 2008

which expressed a number of concerns about ‘the views of students and

those responsible for the IPL programme’ (GMC 2008, p12). In particular

the GMC noted that there were high numbers of critical comments from

both students and clinical staff about the programme, and that while

students understood the aims of the programme, the content and

timetabling did not facilitate them being met. The consequence of this, the

GMC concluded, was that potentially ‘professional stereotyping is

reinforced rather than reduced’ (GMC 2008, p12). The recommendations

made from the QABME review included Southampton looking at

restructuring their IPL provision, and asking the School to demonstrate

that the delivery of IPL met the needs of medical students. One might

therefore question whether the scale of that particular programme was

sustainable, and the evidence from the GMC report suggests that it was not,

or at least not in a way that was viewed as meeting both the needs of

medical students and the aims of the IPE programme. This highlights

further the difficulties in discussing programmes or their elements that are

perceived to be ‘unsuccessful’ (or perhaps less successful than interested

parties would like them to be), as these are rarely discussed in published

papers, rendering information on the programme difficult to find, analyse,

or build future learning on.

The other three Common Learning Pilots were not continued for similar

reason as the New Generation project, although research and final reports

are available on some. Of particular interest to this research is a case study

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of the Interprofessional Learning in Practice in South East London (ILP)

which notes that the potential size of the programme (5,900 students per

year) was a barrier to overcome, with the result that the programme was

piloted rather than introduced to the entire cohort at once. The pilot

involved 610 students from 10 H&SC professions (D’Avray et al. 2007);

each student attended three two-hour sessions in a mixed group of 7 – 10

linked to a clinical area. Session one involved constructing a map of a

patient journey; session two involved a visit to practice in pairs to

interview informal carers and professional staff, and to review client

documents; and session three involved students meeting to discuss what

they had experienced in practice. While the case study suggested that

students generally enjoyed positive experiences from the ILP programme,

it was noted that the recruitment of facilitators was uneven, with a lack of

engagement from some professions, and particularly in medicine, where

staff supported the course but did not volunteer to facilitate sessions

(D’Avray et al. 2007). Lack of engagement by medical professionals was a

theme in the in earlier IPE literature (Whitehead 2007) but did not arise as

an issue for the ALPS CETL. Indeed, there was instead a recognition that

engagement of the Medical School had been informed by strong leadership

from the Director of the CETL, a finding similar to Fook et al. (2013) who

noted that inspiring leadership from the medical faculty ensured

engagement by all staff. The ILP case study also suggested that while the

ILP exercise had proven to be deliverable, this was probably because of its

‘modest size’, suggesting that a larger programme (i.e. which all students

could have attended) would have been too costly and difficult to sustain

(D’Avray et al. 2007). To embed the programme, it was suggested that the

responsibility for running it would need to be moved away from the project

team and into the health schools (D’Avray et al. 2007). This was similar to

the ALPS experience, where the project was seen as innovative and was

well supported, but the motivation for making it happen and, in particular,

the administrative functions were carried out by a core project team. Once

these resources were no longer funded or existed, it was unlikely that

institutions would carry forward the activity by themselves (although in

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the case of ALPS, elements of the programme were adopted by individual

professions or institutions). Again, this raises questions about the

sustainability of large-scale IPE programmes, and in particular those like

the ILP, of which it was suggested:

…it is not possible to prove that patient care will benefit from this

particular course… (D’Avray et al. 2007, online)

In a time of restricted budgets, it seems unlikely that IPE on this scale,

which cannot be demonstrably linked to improvements in patient care,

would be continued.

One larger-scale IPE course that still in operation is the Aberdeen

Interprofessional Health and Social Care Education programme. Begun in

2003/4 as a series of interprofessional workshops for all first-year H&SC

across Robert Gordon University and the School of Medicine and Dentistry

at the University of Aberdeen, this IPE programme of classroom based

workshops is now embedded in first and second year curricula across ten

professional courses at these institutions (Aberdeen website). It is noted

that from year three onwards, IPE is experienced in practice placements

(Aberdeen website). An evaluation of this work prepared for the Scottish

Government (who funded the evaluation) was published in 2008, although

information presented in it was primarily based upon exploring student

perceptions of IPE and interprofessional working. The extent to which the

programme has had any benefit for patient care is once again unknown,

although it is interesting to note that this programme, which grew from a

funded pilot, has been sustained while other programmes have not. The

model of larger-scale IPE, involving delivering classroom-based workshops

to all H&SC students within an institution or with a partner institution, is

possibly more common-place now, with at least three of the five ALPS

partners now incorporating it into their own IPE teaching. While the

Aberdeen model was of particular note in 2008, when IPE teaching on this

scale was less usual, it is only the length of time this programme has been

sustained which is now of interest. With a lack of research or evaluation

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material, it is also not possible to understand the impact of this programme

on patient care or on students’ ability to work as part of an

interprofessional team in a meaningful way.

The most similar noteworthy programme of work to ALPS was the

CETL4Health North East, which was again a HEFCE-funded CETL that

involved a collaboration of five Higher Education Institutions and a number

of NHS partners. CETL4HealthNE was very similar to ALPS in that the

interprofessional education aspect was only part of a programme whose

overall aim was that H&SC students should be ‘fit for purpose, fit for

practice as well as fit for award’ (Powell and Scott 2013). In the final

evaluation of the CETL (which should be subjected to the same caveats

regarding purpose and authorship as the ALPS final evaluation) it was

suggested that:

For us, learning needs to impact not only on outcomes for students

but also, through them, on outcomes for patients.

(Hammond et al. 2010, p11)

To recognise this impact, CETL4HealthNE used their fellowship scheme,

although it is not made clear what impact on patients was recorded. IPE

was one of six key areas for this CETL, which aimed to expand its partners’

existing IPE into ‘new contexts and with new participants’ (Hammond et al.

2010, p13). The report notes that there was a ‘considerable expansion of

IPE across partners’ (Hammond et al. 2010, p13), including engagement of

new professions as participants, but again it is not clear how much was a

direct impact of the CETL activity and how much may have occurred in

project partners anyway. However, the CETL secured continuation funding

and went on to deliver two practice-based IPE intitiatives whose evaluation

is presented in an extensive report (Powell and Scott 2013). This detailed

document describes the two initiatives, and drawing on Pawson and

Tilley’s (1997) ‘realistic evaluation methodology’, it adopts a methodology

to explore how ‘context + mechanism = outcome’ can be used to interpret

the processes of delivery of ‘interprofessional medication safety seminars’

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(Powell and Scott 2013, p3). The evaluation found that one of the main

benefits identified by students for the session entitled ‘Hard Day’s Night’

was the ‘realism’ that it offered: students perceived that they could practice

roles and responsibilities under pressure in real-life situations (Powell and

Scott 2013, p5). The relevance of the IPE to student’s future roles was

therefore a key feature of this programme. In the second programme of

work, ‘Patient Safety Day’, findings included the fact that there was a need

for facilitators to be trained specifically in IPL facilitation, was avoiding

confusion about the role of the facilitator in sessions (Powell and Scott

2013, p6). Powell and Scott also found evidence to suggest that as a result

of the session, students:

…were able to identify major patient safety incidents/errors and

recognise their own and others’ professional practice could

contribute to them, but were less certain about identifying ‘minor’

errors and ‘near misses’. (2013, p7)

It is very difficult to do justice to such a comprehensive evaluation in this

short summary, but the points covered illustrate cohesion with other

research on IPE facilitation (see Chapter Three) as well as point to a legacy

from a larger-scale IPE programme (numbers accessing the programme are

not clear) that does at least have some impact on patient safety, while other

large-scale IPE projects (and IPE initiatives in general) have struggled to

evidence this.

The following section explores the impact of the ALPS programme on ALPS

staff (from their own perspective) as well as any apparent wider legacy of

the ALPS programme on IPE, collaborative practice, or organisational

culture.

5.6 Impact of the ALPS programme staff

After discussing some existing documents relating to outcomes of the ALPS

programme, this section uses data collected specifically for this study in

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order to explore perceived impact of the ALPS CETL on the staff involved in

delivering it.

44 of the 289 (15%) NHS staff who responded to the survey had heard of

ALPS. As the survey was in part distributed via national internet forums

and respondents could subsequently be from any part of the country, this is

not unexpected. The majority of those who had heard of ALPS had done so

via a leaflet or presentations at conferences and were not involved with

any aspect of delivering the programme. Of the 35 academic staff who

responded to the survey, 30 (86%) had heard of ALPS. Six had been

members of an ALPS working group, but again a majority of the group had

only heard of ALPS because they worked for one of the ALPS partner

institutions. There were therefore insufficient survey respondents who

had been engaged in the ALPS programme in any meaningful way to

explore potential differences in responses to survey questions between

those involved with ALPS and those who were not.

Similarly, none of the NHS staff interviewed had been involved in delivering

the ALPS programme, although some had heard of it. Again, the way

respondents were recruited (via self-selection from completing the survey)

may have impacted upon that. There were not many practice staff directly

involved with ALPS, and in order to interview them, I would have needed to

approach them directly. By the time I was conducting interviews for the

research, many had moved on to other posts and their contact details were

not known to those who had worked with them.

However, all academic interview respondents originally approached to

take part were selected because of their involvement in the ALPS

programme. As a result of referrals made during these interviews – usually

to colleagues involved in other IPE programmes – three academic

interview respondents had not been involved with ALPS directly, although

all were aware of it, as they all worked at ALPS partner institutions.

Themes emerging from interviews concerning the impact of the ALPS CETL

programme on staff are therefore drawn predominantly from 14 of the 17

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interviews with academic staff, although all 17 interviews were analysed in

the same way. Where any respondent quoted was not directly involved

with the ALPS programme, this is noted if relevant. It should also be

observed that while ALPS was a large programme with many strands of

work, the discussions here, unless otherwise stated, refer to

interprofessional elements of ALPS, which was the focus of the ALPS-

related interview questions (see Appendix 7).

5.61 Themes from interview data

The following discussion outlines themes that arose from interrogating

interview data. However, the section on ‘ALPS Legacy’ is more descriptive

of the narrative emerging from all the interview responses about the

impact staff members believed the ALPS programme had had on them as

individuals and on the institutions they worked for; this is because

capturing the range of responses was important for the ensuing discussion.

5.61i Some partners benefitted more than others

There was a general feeling among participants that some ‘got more out of’

ALPS than others:

I think it is fair to say there were pockets of people and courses and

students who got more out of it than others. (HEI02)

In particular, there were a number of suggestions that those who most

benefitted from the ALPS programme were smaller professions /

institutions, who enjoyed benefits that would not have otherwise been

achieved. For example, respondent HEI4 reflected how involvement in

ALPS had put the institution for which he worked in a different position

regarding local policy discussions from other local institutions who had not

been ALPS partners:

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For [ALPS institution] it has really positioned itself strongly within

the Strategic Health Authority…recently…there’s been a working

group which included all the universities and reps from all the

services and [ALPS institution] sits in a different position because of

ALPS – I do think we would have continued to be sidelined…it has

[also] made it easier for us to move to international working which

we didn’t do five years ago. (HEI04)

Similarly, HEI17 reflected on the benefits of ALPS involvement for his

profession:

I think that we [Audiology] were looking for inroads into places and

ALPS provided that. It gave you a reserved place at the table and

that can often be the most difficult thing to do, that foot in the

door…because I was involved in ALPS I was invited to that second

project with the School of Medicine so that wouldn’t have happened

otherwise. (HEI17)

These kinds of responses were not in evidence from respondents who

worked in larger institutions / professions, who possibly already have

more opportunities to engage in policymaking or work across professional

boundaries; however, they do tie in with the theme identified in work on

ALPS by Hargreaves et al. as ‘we got further than we would have done on

our own’. The implications of this finding are also linked to the second

emergent theme from interviews with ALPS participants: that IPE was

already occurring in most ALPS partners in one form, but not necessarily

with the range of professions involved in ALPS.

5.61ii IPE / collaborative practice happens anyway

One of the difficulties participants had in describing the ‘legacy’ of the ALPS

programme of work was that many institutions involved in ALPS already

had some elements of IPE established or set-up during the life of the

programme. As such, some participants could not separate out changes to

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IPE and attitudes towards it that may have occurred as a direct result of the

programme:

I’m not sure really, I think, I’m not sure if that came from ALPS or if it

came from elsewhere but we have a really interprofessional way of

managing our placements. (HEI16 not directly involved in ALPS)

For some respondents, the idea that IPE happened anyway was marked by

the way they viewed their own profession / professional identity as being

interprofessional:

I think opportunities to work together, see, as an Occupational

Therapist it is very much part of our philosophy that the value of

work, the value of being engaged in a meaningful purposeful

occupation together in terms of how it impacts on the way you think

and the way you behave is really strong…actually the opportunity to

work together is key. (HEI04)

I come from a strong tradition, I was a Sure Start midwife, and a

teenage pregnancy midwife, so my professional background is

collaborative working, I don’t come from a uni-professional

background, and I do think that has a fundamental difference in

your – your perspective is different. (HEI10)

For other respondents, good interprofessional practice was something they

either often experienced at work or witnessed happening anyway within

practice settings:

…in many ways ALPS and other things have just reinforced my

prejudices about what matters to…people, and what matters to

professions in terms of really working together as part of a

cohesive team…I see on my base ward…there is much more

professional respect, we can run a very flat structure in terms of

everybody pitching in. (HEI07)

Separating out the ‘ALPS effect’ on all these existing perceptions of IPE is

therefore impossible. Nevertheless, ALPS partners did often state that

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what the ALPS programme did was facilitate collaboration both across

institutions and across professions that would not have occurred

otherwise. In the institutional context this was not viewed as surprising

given that ALPS brought together a number of HEIs who had previously

been ‘competitors’ for both research funding and students.

I’ve got a greater awareness of what is going on in other

universities…Sometimes it takes a project like that doesn’t it to

force people to work together because people don’t have time to

do it once the institution is committed to it you have to do it.

(HEI08)

…it helped to crystalise and develop the professional learning and

the interprofessional learning, it was a fantastic time for dialogue

with other professions and that has a legacy…it’s also opened links

between the school of healthcare and the medical school… (HEI17)

This ties in with the discussion in research by Hargreaves et al. about the

extent to which emerging collaborations from ALPS were ‘natural’ or

‘manufactured’. To a certain extent, however, this does not seem to matter;

some of the impact of the ALPS programme appears to have been to

improve interprofessional working and relationships across professional

boundaries for academic staff involved, though not because of the adoption

of specific interprofessional initiatives that ALPS developed. Instead, it

appears that it was simply opportunities that arose to work with

professions that might not otherwise have been encountered which had a

longer lasting effect.

There are several implications of the two foregoing themes from ALPS

participant interviews. In particular, as the smaller professions (and

institutions) both claimed and were viewed by others to have benefitted

most from the programme, important philosophical questions are raised

for ‘larger professions’ or institutional partners regarding their role in IPE.

Specifically, is there any sense in which these ‘larger professions’ (probably

characterised as medicine and nursing) have a responsibility to ensure that

185

smaller professions are i. encouraged to take part in and / or ii. involved in

IPE initiatives, to ensure that best-practice is developed and shared as

widely as possible (where relevant)? Ultimately it may be that involving

partners ‘less likely’ to be involved in IPE results in benefits larger

professions if it means that all professions prepare for collaborative

practice together. This is conjecture and a definitive answer is unknown,

but it is an interesting question to raise while thinking about the future of

interprofessional programmes.

5.61iii Politics and existing working cultures as a barrier to the

implementation of IPE

As well as identifying benefits of the ALPS programme, participants raised

a number of issues which they perceived to be barriers in implementing a

large scale IPE programme. For the most part, these can be described as

‘politics and cultural reasons’ why IPE programmes were seen as difficult

to implement, aligning with the findings of Hargreaves et al. (n.d.)

However, in this research, there were several comments about specific

resistance to the ALPS programme:

I think there’s always been a bit of resistance here to ALPS and it’s

always felt very hard in trying to promote it…I don’t think there’s

ever really been a positive attitude towards interprofessional

education. (HEI1)

…it just seemed to me that some institutions seemed to be much

more on board with it… (HEI2)

In addition to HEI1 suggesting general resistance to IPE within the

institution, it was also suggested by the same participant that resistance to

ALPS may have stemmed from the fact that the bid was written by more

senior staff who did not subsequently lead or engage with the programme,

handing it on to other people to ‘do the work’. Connected to this was the

notion (expressed by a number of participants) that ALPS was seen as just

‘one more additional thing’ to be done:

186

I felt that, as so often happens in big organisations it became a kind

of bureaucratic process rather than ‘look what exciting learning

and teaching innovation this is’ so people were kind of a bit turned

off about it thinking ‘oh this is another additional stress’ or

whatever rather than ‘wouldn’t it be great to get involved in this’.

(HEI2)

I think there’s a combination of people not liking change and

anything new is confusing so there was some resistance to change,

some of it was just the sheer practicalities of things being seen as

an add-on and an extra piece of work. (HEI15)

Existing ‘political’ concerns and the culture of institutions were also

proposed as a barrier to successful implementation of IPE:

Well they have their own activities but I think probably the bottom

line is that they are in another department and it’s not, it’s

probably the wrong thing to say but it’s easier…it’s more political

that it doesn’t happen

(HEI3 on the exclusion of a profession from a local IPE initiative)

I sat on some of the things in relation to the interprofessional

competency things but that didn’t float my boat, I think that was less

about the subject and more about some of the other partners.

(HEI07)

Finally, a number of participants made points which either explicitly or

implicitly implied that professional identity and socialisation processes

were barriers to the implementation of ALPS and / or other IPE:

I think the difficulty is that when students go into practice they

want to succeed, they want to be part of the team, they want to be

liked, they want a job, they want to pass, and I think they will

behave as their mentors behave, because the reality is that if as a

student you challenge then there will be implications for you.

(HEI10)

187

It’s a huge generalisation, but nevertheless some of the feedback

we get, they didn’t know what an occupational therapist was for

example…and similarly from the feedback we get from the

occupational therapists because it’s often around the stereotypes,

and for some individuals it’s around ‘we assumed social workers

only took children away’. (HEI3)

I think it’s probably in all professions, they soon develop a strong

identity and they feel they are exclusive, and therefore no-one else

can be the same as them, and so if anyone that doesn’t have the

label of their own profession is pointless. But what they don’t

realise it that if you actually take those labels off, it’s like a pair of

jeans, a pair of jeans is a pair of jeans, you know whether it’s Levi

or whether it’s Asda… (HEI17)

It is interesting to note, however, that these latter examples concern the

professional identities of students as a barrier for IPE initiatives, and as

such, does not take into account the idea that staff could have influence

over these identities. Only one respondent reflected on the professional

identity and working culture of staff as a potential barrier to the successful

introduction of IPE:

…they’re [staff] not actually that signed up. I think that

they see the value [of IPE], and see the worth, and can talk the talk,

but actually it’s a big jump in doing that. (HEI10)

As evident in the discussion in Chapter Three, the notion of barriers for IPE

stemming from existing working cultures of institutions is relatively

common within IPE literature, and based on these findings, these issues

appear no different in larger scale programmes than in smaller ones.

However, while discussing during interviews how respondents had become

involved in ALPS, it was apparent that the majority of staff, generally

invited to join by managers, got involved in a way that enabled them to

engage only with strands of work that were of most interest to them /

relevant to their current role. The interprofessional element of the ALPS

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programme was therefore led by staff who already had an interest or a role

involving IPE. It was not apparent from interviews that staff not already

interested in IPE got involved in delivering this aspect of the programme

(although staff involved in all aspects of the programme reported benefits

of working with new professional partners, as explored in the previous

sections). This can be explained by the fact that no ALPS activity could

have progressed without working across professional boundaries, given

that the programme had to be implemented across partners. However,

where literature examined in Chapter Three raised questions about the

extent to which IPE needed to be made compulsory to enable for students

to engage with it, this reflection on the ALPS programme also highlights

whether IPE is an ‘optional’ activity for staff and whether they will engage

with it if they feel they do not need to. This returns to the question about

whether professions. and in this instance, individual professionals either

have or should have a responsibility to get involved in interprofessional

programmes, ensuring that best practice is shared.

5.61iv. The ALPS legacy

To fully understand what impact the implementation of a large-scale

interprofessional programme has on staff involved in delivering the

programme, interview respondents were explicitly asked what legacy they

believed the ALPS programme had on their own professional working

practices and on institutions involved in delivering them. None of the

interview respondents felt that ALPS had resulted in cultural or

organisational change for NHS partners involved in ALPS. This was seen in

part as a consequence of there being only a ‘minimal level’ of contact with

NHS staff, who tended to be in Practice Learning Facilitator roles and were

not senior enough to influence organisational change:

I think we failed to influence high enough up at that level we looked

at working with people who took students on placement rather than

their managers. (HEI4)

189

A number of respondents also commented that elements of the ALPS

programme had only just become established when the programme ended,

with the view that five years was not a long enough period to achieve all

the programme’s aims:

I think unfortunately it was only a five year project, had it been a

ten-year project, we were just beginning to get some really successful

hits with our tools, but obviously as research projects go, there are

just a few of us left trying to still sort of infiltrate you know systems

and organisations. (HEI09)

If you accept that there was major change in practice needed, I think

we need longer…I think that would have been very interesting to see

if there had been any more impact. (HEI10)

The theme that the CETL programme was not ‘long enough’ to achieve the

CETLs’ ambitious aims was highlighted in the final CETL report (SQW

2011). The idea that longer funding periods result in more successful IPE

projects was, however, dispelled by Fook et al. (2013) who highlight that, in

contrast to the four well-funded Common Learning Pilots:

…recipients of much less or no external funding, managed

successfully to introduce, sustain and evaluate innovative

examples of IPE (Colyet 2008; Joseph et al. 2012; Miers et al.

2005). (Fook et al. 2013, p286)

The view for some that the CETLS would end when the funding ended,

rather than be developed and embedded may explain the lack of longer-

term impact, rather than the time-period for the programme itself being

the issue. For ALPS specifically, where embedding the tools was a specific

aim, it may be the case that the fact that as a number of staff moved or

changed role towards the end of the ALPS programme (many, almost

ironically, being promoted thanks to their involvement in the ALPS

programme) there were too few original ALPS staff left with the right

knowledge of the ALPS tools to establish a longer term legacy that involved

using them.

190

One of the most interesting findings about the impact on staff that

involvement in implementing an interprofessional programme had is that

all participants involved in delivering the programme reported positive

personal experiences as a result of this. Many respondents commented on

promotions or job opportunities that had arisen as a result of having a large

interprofessional project on their C.V.s, with both respondents, HEI03 and

HEI08 saying that they had been able to move to more interprofessional

roles specifically because of their involvement in ALPS. It appears

therefore that being seen to have an involvement with ALPS as an

interprofessional programme of work is a positive thing, regardless of

whether any improvements in IPE or collaborative practice were

evidenced. In line with the finding mentioned earlier concerning increased

working with new partners, many respondents described their own

personal network of contacts expanding across professions and

institutions, and having retained these contacts after the ALPS programme

ended.

There was also some evidence from respondents that ALPS had an impact

on interprofessional assessment and interprofessional working practices

within the ALPS partner HEIs. In some institutions or professions, the

ALPS tools, or elements of the tools, had been adopted and were still in use

(this was mentioned by respondents from three different HEIs). More

importantly for the majority of respondents, however, was that ALPS had

‘raised awareness’ of co-operation between professions (HEI05), ‘proved

the concept’ of both peer and interprofessional assessment (HEI09), and

resulted in a lot of learning about interprofessional working that was now

being used to inform new IPE developments (HEI04, HEI07, HEI08, HEI17).

The biggest impact of ALPS from the perspective of participants in this

study therefore appears to relate to ‘lessons learned’, which has resulted in

much progress being made by individuals and institutions, but not

explicitly because of adoption of interprofessional tools developed by ALPS,

as originally hoped.

191

The final section of this chapter will examine how far it has been possible

to answer the research question posed concerning the impact of a large-

scale interprofessional programme. In light of the findings about the ALPS

programme as well as discussion of other larger scale initatives, it also

questions whether large-scale IPE is sustainable.

5.7 Summary

The purpose of this case study was to answer the question: ‘what impact

does the implementation of a large-scale interprofessional programme

have on staff involved in delivering the programme?’ The responses to this

question based upon the case study findings presented here, and to all

other research questions posed at the start of this thesis, is examined in

Chapter Seven. The main themes of the chapter have been identified as

positive personal experiences that arose for CETL staff and improved

collaborative working relationships, although these have been identified

alongside perceived barriers to IPE. The discussions in this chapter also

raised questions about both the sustainability of larger scale IPE

programmes and whether larger professions should have any

responsibility to involve smaller professions in IPE initiatives. This

responsibility, would, theoretically, ensure that best practice was shared

with smaller professions and create opportunities for smaller partners

which may not previously have existed. This raises the notion of an

‘interprofessional responsibility’ on a whole-profession scale, the

implications of which would have far-reaching effects for the introduction

of future IPE initiatives. The conceptualisation of such a ‘responsibility’, its

implications, and its relationship to ‘interprofessional responsibilities’ on

an individual level, are discussed in the concluding chapter (Seven). The

following chapter examines the data gathered from the surveys and

interviews in order to explore the other research questions posed in

Chapter One.

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Chapter Six

Exploring perceptions of professional identity via

experiences of interprofessional education and

collaborative practice

6.1 Introduction

This chapter draws upon survey and interview data gathered for this thesis

to explore how both practicing and academic H&SC staff perceive

‘professional identities’, and how they interpret their experiences of IPE

and collaborative practice. It is questioned whether there is an

interrelationship or ‘link’ between perceptions of interprofessional

experiences and perceptions of professional identity. Specifically, the

analysis seeks to address the following questions:

1. How do practicing H&SC staff conceptualise their professional

identity, and the professional identity of other professions with

whom they work or learn?

2. Do practicing H&SC staff perceive that ‘professional identities’ are

reinforced, challenged or changed by IPE and / or collaborative

practice?

3. What implications do conceptualisations of professional identities

and IPE have for the implementation of educational initiatives

aimed at improving teamwork between professions for the ultimate

aim of improving service user care?

The purpose of this research is to understand if interpretations of

professional identity by members of H&SC staff have implications for the

way IPE is developed and delivered. Implications of findings from this

research are discussed during both this and the final chapter.

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6.2 Survey respondents

321 survey respondents represented 15 different professions (see Table

4.1, Chapter 4). 288 respondents worked solely or primarily practicing

their chosen profession; 33 were solely or primarily academic staff. Seven

professions were represented by over twenty respondents or more (see

Table 4.1, Chapter 4). Where comparisons of respondents by profession

have been undertaken, it is between these seven professions only; the 20

other respondents, representing eight professions, were excluded from this

type of analysis. As practicing and academic staff were asked slightly

different questions regarding their professional histories and roles, these

are described here separately.

The majority (60%, n=172) of practicing staff who responded to the survey

described themselves as a ‘senior’ members of staff (having been given the

options to rate themselves as junior, middle or senior). 63% of practicing

staff had graduated from their chosen profession 11 years or more ago.

Only 2.2% (n=7) of respondents had graduated within the last 12 months.

The self-rated seniority was an approximate indicator of time since

graduation, and age, although there were three respondents who rated

themselves as ‘junior’ who had graduated over six years earlier and two

respondents over 45 years old who also stated that they held junior roles.

The purpose of asking respondents to rate their seniority was to

understand whether respondents at different levels had similar amounts of

interaction with groups of students (with a view to exploring the

implications for socialisation processes). Academic staff were not asked to

rate their seniority, as they were likely to be in contact with students

regardless of position. However, they were asked how long they had

worked in higher education (HE). The majority (88%) (29 of 33) had done

so for over six years, and all for a minimum of three years. Of the eight

(24%) academic respondents still working / practicing in their chosen

profession, five (15%) did so once a week or more regularly.

194

The majority of survey respondents were therefore quite ‘established’ in

their professions, with few respondents having only just qualified. This

could be considered both a strength and a limitation of this data. In a

project concerned with exploring professional identity, the fact that the

majority of respondents have spent some years practicing their profession

or teaching elements may mean they are more certain of their ‘professional

identities’ and what they mean to them. However, a lack of respondents

only recently qualified means that differences in opinion between newer

graduates and more established professionals may not be apparent.

6.21 Experiences of IPE

61% of respondents reported having undertaken some IPE as part of their

professional training. This was a mixture of classroom and practice based

experiences at both pre- and post-registration level (Table 6.1).

Table 6.1: Types of IPE experienced by survey respondents

Table 6.1 also highlights that respondents’ experiences of IPE were highly

varied, and the majority of those who had experienced IPE had received it

only as part of their post-registration education. Perhaps unsurprisingly,

given that IPE has only been come to prominence in the last decade, staff

who described themselves as ‘junior’ were more likely to report having

experienced IPE as part of their education (Table 6.2). It should be noted

that responses to this question relied upon respondents remembering

Type of IPE experienced N % Classroom-based pre-registration only 19 6.0 Work-based pre-registration only 14 4.4 Classroom and work-based pre-registration 16 5.1 Classroom based pre-registration and post-registration 17 5.4 Work-based pre-registration and post-registration 13 4.1 Classroom and work-based pre-registration and at post-registration level

39 12.3

At post-registration level only 74 23.4 No 113 35.8 Don’t know / can’t remember 11 3.5 Total 316 100

195

specific from their professional training, which, it is acknowledged, may

contribute to inaccuracies in the data. However, based on responses given,

statistical tests indicate that results are unlikely to be due to chance. The

Chi-square result χ2=10.194, d.f.=2, p=0.006 indicates significance at the

1% level – i.e. that only 1% of the time would a value this high or higher be

expected if there was no association in the population. The Cramer’s V2

value of V=0.192 also suggest a small association between level of seniority

and likelihood of having experienced IPE.

Table 6.2: Reported experience of IPE and self-rated seniority

Junior Middle Senior Had any IPE? n % n % n %

Yes 25 92.5 53 64.6 102 61.1 No 2 7.4 29 35.4 65 38.9

Total 27 100 82 100 167 100 n=276

Nursing staff were much less likely than the other professions to report

having experienced IPE as part of their education (Table 6.3). While a

similar number of doctors also said they had not received any form of IPE,

the percentage saying that they had experienced IPE was much closer to

that of all other professions who responded. The literature review did not

identify that any professions were more or less likely to be involved in IPE

(although Whitehead 2007 did suggest that doctors were sometimes less

willing to collaborate in IPE due to perceived threats to status), but there

was no evidence in the literature that nursing is likely to be excluded from

such initiatives.

2 The Chi-square and Cramer’s V tests are explained in full in Chapter Four.

196

Table 6.3: Experience of any IPE as part of professional training by professional background

Medicine Midwifery Nursing Occupational

Therapy

Physiotherapy Social Work Speech and

Language

Therapy

Had any

IPE? n % n % n % n % n % n % n %

Yes 65 73.0 16 80.0 17 37.0 19 67.9 20 60.6 15 71.4 33 62.3

No 24 27.0 4 20.0 29 63.0 9 32.1 13 39.4 6 28.6 20 37.7

Total 89 100 20 100 46 100 28 100 33 100 21 100 53 100

197

The finding here suggests that nurses who responded to this survey had

experienced less IPE than other professions who responded, or may be less

likely to recognise that they have experienced IPE. Again, statistical tests

suggest that there was a relationship between these variables. The Chi-

square result χ2=20.837, d.f.=6, p=0.002 indicates a significance at the 1%

level, and the Cramer’s V value was V = 0.268.

If one assumes that IPE experienced by participants had achieved its aims

in improving communication and / or understanding of different

professional roles (although findings from the literature review in Chapter

Three suggests this could be an inaccurate assumption), it might be viewed

as a ‘positive’ result that over half of respondents reported that they had

received some form of IPE. However, the extent to which this represents

experiences of IPE as understood as a situation in which professions have

learnt with and from one another is questionable. In addition to reporting

IPE experiences, respondents were asked what they understood IPE to be,

using an open text response. There were a variety of responses, many of

which might be labelled as misunderstandings of IPE to various extents:

One profession teaching others (N44)

Many professions being taught together (N103)

Different professions having some lectures and teaching in common

(A21)

There were also descriptions of IPE that more accurately reflected its

generally accepted definition and aims:

Learning with and from other professionals in a true spirit of mutuality.

Training, observing and co-operating across professions with

practitioners from different disciplines. (N206)

Being aware of variety of disciplines involved in patients care and how

these wide variety of professions interact and how this can be taught /

learnt. (A4)

198

Reported experiences of IPE bore no relation to whether an accurate

description of IPE was given. However, more respondents were able to

define the ‘main purpose’ of IPE than were able to describe it accurately:

That where feasible, undergraduate students of different courses share

training, in order to cultivate shared knowledge and identity and to

cultivate mutual respect and understanding of each others' roles. It

should and can also continue once qualified. (N82)

Understanding each other so that different professions work as a team

which ultimately provides quality of care service. Improves

communication which provides increases safety for the patient / public

/ client. (N111)

While the accuracy of respondents’ self-reported participation in IPE can

be questioned, the fact that many respondents could identify with the aims

of IPE is ‘positive’ in terms of recognising that one of the drivers for IPE is

improved patient care. As respondents were not always able to accurately

describe IPE but were more likely to identify with its aims, this raises the

question about whether ‘IPE’ is merely a label understood by academics to

mean something quite specific, but less likely to be recognised or

remembered by practicing members of H&SC staff. The extent to which

this matters is also debatable if H&SC staff (or a majority of them) can show

an appreciation of what IPE initiatives attempt to achieve.

6.22 Opinions on IPE

Based upon their experiences, respondents were asked to rate how

successful they believed IPE could be in improving communication skills,

team-working skills, enabling students to understand their own limitations

and in improving patient or service user care. Respondents were most

pessimistic concerning the ability of IPE to help students understand their

limitations, but 75% rated IPE as successful (scoring it 4 or 5 out of 5) in

improving team-working skills (see Figure 6.1).

199

Figure 6.1: Respondents’ ratings of how successful they believe IPE

can be in achieving certain aims

There were no observable differences in opinions concerning IPE by

gender, age or profession. There were also no observable differences

between those who had experienced any type of IPE, and those who had

not, concerning the perception that IPE might be successful in some of

these aims. Given the range of different forms of IPE experienced by

participants, combined with the difficulty respondents had in recognising

or recalling IPE, this finding may be unsurprising. It is still worth noting,

however, that for participants in this study, experiences of IPE did not

appear to result in different opinions regarding its likely success in

achieving its aims. This may have implications for opinions on IPE such

members of staff are prepared to express in front of students.

9.9 8.6 11.2 8.9

1 0.3

2.6 1.6

6.4 2.2

12.2

3.8

21.4

12.7

31.1

17.3

38

40.8

28.5

36.7

23.3

35.4

14.4

31.6

0%

20%

40%

60%

80%

100%

Improvecommunications

skills (n=313)

Improve team-working skills

(n=314)

Help studentsunderstand theirown limitations

(n=312)

Improve patientcare (n=313)

No experience 1 - Least successful 2 3 4 5 - Most succesful

200

6.23 Attitudes towards collaborative practice

Respondents were asked their opinion on a series of statements related to

how they felt about their professional roles and about various aspects of

working with other professions. While 86% of respondents agreed with

the statement that there are ‘tasks which my profession is responsible for

that no other profession can undertake’, only 10% of respondents agreed

that they ‘preferred to work’ with members of their own profession (Figure

6.2). This suggests that recognition of role boundaries by respondents

does not equate to ‘silo working’. However, results also indicate that there

remains room for improvement; just over 30% of respondents did not

agree that their opinion was always listened to and valued when working

with other professions, and nearly 40% did not agree with the statement, ‘I

think there is a lot of respect between professionals at work, regardless of

which profession they belong to’.

Figure 6.2: Respondents’ views on collaborative practice

0.6

16.9

1.6 3.1 8.4

46.1

13.5 18.2 5

27

17.9

16 34.6

8.8

58.2 54.7

51.2

1.3 8.8 7.9

0%

20%

40%

60%

80%

100%

There are tasks that myprofession is

responsible for that noother profession canundertake (n=320)

I prefer working withmembers of my ownprofesson than with

members of otherprofessions (n=319)

When I work withother professions, my

opinion is alwayslistened to and valued

(n=318)

I think there is a lot ofrespect between

professionals at work,regardless of which

profession they belongto (n=318)

Strongly disagree Slightly disagree Neither agree nor disagree

Slightly agree Strongly agree

201

Table 6.5 I think there is a lot of respect between professionals at work, regardless of which profession they belong to Medicine Midwifery Nursing Occupational

Therapy Physiotherapy Social Work SLT

n % n % n % n % n % n % n % Strongly Agree 7 7.5 1 4.8 2 4.4 3 10.7 2 6.1 2 9.1 8 14.3 Slightly Agree 62 66.7 9 42.9 21 46.7 15 53.6 22 66.7 6 27.3 26 46.4 Neither agree nor disagree

8 8.6 3 14.3 8 17.8 5 17.9 6 18.2 4 18.2 12 21.4

Slightly disagree 13 14.0 7 33.3 13 28.9 4 14.3 3 9.1 6 27.3 10 17.9 Strongly disagree

3 3.2 1 4.8 1 2.2 1 3.6 0 - 4 18.2 0 -

Total 93 100 21 100 45 100 28 100 33 100 22 100 56 100

Table 6.4 There are tasks that my profession is responsible for that no other profession can undertake Medicine Midwifery Nursing Occupational

Therapy Physiotherapy Social Work SLT

n % n % n % n % n % n % n % Strongly Agree 55 58.5 11 52.4 13 28.3 9 32.1 18 54.5 10 45.5 39 69.6 Slightly Agree 30 31.9 10 47.6 16 34.8 13 46.4 14 42.4 9 40.9 13 23.2 Neither agree nor disagree

2 2.1 0 - 6 13.0 4 14.3 0 - 1 4.5 1 1.8

Slightly disagree 6 6.4 0 - 10 21.7 2 7.1 1 3.0 2 9.1 3 5.4 Strongly disagree

1 1.1 0 - 1 2.2 0 - 0 - 0 - 0 -

Total 94 100 21 100 46 100 28 100 33 100 22 100 56 100

Tables 6.4 and 6.5: Opinions of task specificity and respect between professionals by professional group

202

Consistent with Etzioni’s (1969) observation that nurses possess a less

specialised body of knowledge, nurses who responded to this survey were

less likely to agree with the statement that ‘there are tasks that my

professions is responsible for which no other profession can undertake’

(Table 6.4). Social workers were much more likely to disagree with the

statement about there being respect between professionals (Table 6.5),

which may support the view discussed in Chapter Two that in complex

cases, social workers are often portrayed as ‘folk devils’ (Warner 2013;

Clapton 2013). As a large number of cells in these tables (>50%) had

expected counts of less than five, it was not possible to run statistical tests

on these cross-tabulations with accuracy.

Interestingly, results from this part of the survey appear to suggest that for

NHS staff, effective collaborative practice comes with experience. Junior

members of staff were more likely than senior staff to agree that they found

it easier to communicate, and preferred working with, members of their

own profession (Figure 6.3).

Figure 6.3: NHS respondents’ attitudes towards collaborative practice

by self-rated level of seniority

0

16.3 22.2

3.4 16.3 19.4

25

37.2 31

41.4

48.8 45.3 21.4

18.6 28.1

20.7

24.4 28.8

46.4

23.3 17

27.6

8.1 6.5 7.1 4.7 1.8 6.9 2.3 0

0%

20%

40%

60%

80%

100%

Junior(n=28)

Middle(n=86)

Senior(n=171)

Junior(n=29)

Middle(n=86)

Senior(n=170)

Stronglyagree

Slightly agree

Neither agreenor disagree

Slightlydisagree

Stronglydisagree

At work I find it easier to

communicate with members of

my own profession than

members of other professions

I prefer working with members

of my own profession than with

members of other professions

203

This is important as it highlights that some attitudes or opinions towards

collaborative practice (and possibly IPE) may only come with experience,

and that it cannot be ‘taught’; rather, these ‘behaviours’ are learned over

time.

The implications for those looking to prepare students for collaborative

practice may involve reconceptualising IPE and its aims, recognising that

IPE may not lead directly to improved communication between

professionals, but can result in an understanding that good communication

between professions is important, and that each profession has a

responsibility to ensure this occurs for effective patient care.

6.24 Perceptions of professional identity

Respondents were asked their opinions about how they felt about their

own profession, and the concept of professional identity as a whole. Results

reinforced the individual nature of experiences of identity: 16.4% of

respondents felt that being a member of their profession always defined

who they were, while 4.7% stated that it never did (Figure 6.4).

Similarly, 35% of respondents felt that they always belonged to their

profession where 6% stated that they seldom or never did. There were no

observable differences between responses by age, gender, different

professional groups or seniority, and length of time since graduation.

Responses to the second set of statements also highlighted the fluid nature

of identity and how it can mean different things at different times. Over

91% of respondents agreed that they had a clearly defined professional

identity and role, but 48% of respondents agreed that they preferred not to

be defined by their profession outside of work. Only 3.5% of respondents

agreed that the idea of having a professional identity is now ‘out of date’

and irrelevant (Table 6.6).

204

Figure 6.4: Respondents’ perceptions of professional identity

Table 6.6: Respondents’ opinions on professional identity and role

boundaries

I have a clearly

defined

professional

identity and role

I prefer not to be

defined by my

profession

outside of work

The idea of

having a

professional

identity is out of

date and

irrelevant now

n % N % n %

Strongly agree 126 39.6 42 13.2 - -

Agree 164 51.6 109 34.3 11 3.5

Neither agree nor

disagree

17 5.3 90 28.3 52 16.5

Disagree 9 2.8 52 16.4 178 56.3

Strongly disagree 2 0.6 25 7.9 75 23.7

Total 318 100 318 100 316 100

4.7 0.3 0 0.3

7.2 5.4 4.7 0.9

33

20.4 17

13.5

38.7

38.9 42

40.1

16.4

35 36.3 45.1

0%

20%

40%

60%

80%

100%

Being a memberof my professiondefines who I am

(n=318)

I feel that Ibelong to my

profession(n=321)

I feel that I havestrong ties to my

profession(n=317)

I am pleased tobe a member ofmy profession

(n=319)

Always

Often

Seldom

Sometimes

Never

205

Academic staff were asked one additional question about whether they

viewed their identity as more of a teacher / educator, the profession in

which they qualified, or rather as a mixture of the two. There was an even

split between the number of respondents who felt they were a teacher /

educator and those who felt their identity was a mix; only one respondent

said that they felt that their professional identity was that of the profession

in which they had qualified (Table 6.7).

Table 6.7: Academic staff view on their own professional identity

If asked are you more likely to describe yourself as… n % …a teacher / educator 16 48.5 …the profession I qualified in 1 3.0 …mixture of teacher and profession I qualified in

16 48.5

Total 33 100

The literature review did not identify existing studies in this area, but

perceived professional identity of academic staff may be an important

factor in the socialisation of H&SC students. Although based only on a small

number of respondents, the split result here indicates that this may be a

topic worthy of further research.

6.25 Relationship between perceptions of professional identity and

opinions of IPE

Results did not suggest any relationship between how respondents felt

about their professional identities and their opinions of IPE / collaborative

practice. This was explored by cross-tabulating all statements relating to

professional identity with all those relating to IPE and collaborative

practice. As both these concepts are based on personal opinion and

difficult to quantify with statements, it is perhaps not surprising that there

were no apparent relationships between them in results of a survey.

However, the context of this will be considered when discussing interview

data relating to the same relationship.

206

6.26 Contact with students

Given associations identified between professional identity formation and

‘socialisation’, one final aim of the survey was to establish how much

contact respondents had with students. Most (91.6%) NHS staff stated that

they were ‘sometimes’ or ‘often’ observed by student members of their

own profession. In comparison, 88% of staff said the same about student

members of other professions, although this was more likely to be

‘sometimes’ rather than ‘often’ (Table 6.8).

Table 6.8: NHS respondents’ level of contact with students on

placement

However, staff were less likely to teach or supervise students on placement

from other professions than they were to supervise members of their own

profession. Only 15% of staff stated that they ever assessed students from

other professions (compared to 78.4% of staff who had assessed student

members of their own profession). These findings are not in surprising but

fit with the notion that placement experiences offer a lot of

interprofessional opportunities. However, it is not clear that these are

always used as part of ‘teaching’ or socialising students into thinking about

collaborative practice. The fact that so many NHS staff have contact with

students from their own and other professions reiterates the importance of

Students from own profession Students

observe my work

Supervise students on placement

Teach students on placement

Formally assess students

n % n % n % n % Never 11 3.9 31 11.4 40 14.7 59 21.7 Sometimes 118 42.3 107 39.2 105 38.5 91 33.5 Often 150 53.8 135 49.5 128 46.9 122 44.9 Total 279 100 273 100 273 100 272 100

Students from professions other than own n % n % n % n % Never 32 11.2 180 69.5 126 48.1 217 84.4 Sometimes 202 70.6 63 24.3 112 42.7 26 10.1 Often 52 18.2 16 6.2 24 9.2 14 5.4 Total 286 100 259 100 262 100 257 100

207

exploring perceptions of professional identity and IPE, particularly the

views and opinions students are potentially exposed to during training.

Drawing upon interviews gathered for this research, the following section

explores in depth the views of participants about professional identity and

IPE.

6.3 Interview data

Data explored here is taken from 33 interviews (16 with NHS staff, 17 with

academic staff) carried out for this research. The professional background

of respondents is described in Table 4.2 in Chapter 4. The data presented is

a mixture of narratives and themes that emerged from the interviews, but it

must be emphasised that each interview concerning identity represents the

experiences of only one individual. The purpose of drawing themes from

the interviews was not done to suggest that individual experiences

associated with identity or education and training can be generalised to the

whole population of H&SC staff, but rather to identify common elements in

experiences that might enhance the way the relationship between IPE and

professional identity is understood.

6.31 Conceptualisations of ‘own’ professional identity

While all respondents had their own story to tell about ‘how’ and ‘why’

they became a member of their profession (in this context, the one in which

they most recently qualified and were being interviewed about), there

were some common themes to the narratives respondents developed about

their path to becoming a professional. These are defined here as

professional role as: ‘finding a niche’, ‘convenient’, and ‘not a deliberate

choice’. These elements of narrative are not mutually exclusive; rather,

they represent three common threads of stories participants told about

how they found themselves in their professional roles. Figure 6.5 contains

example quotations for each definition.

208

As illustrated by examples in Figure 6.5, ‘finding a niche’ can take place

very early in a career – for example, while making a decision about which

profession to apply to – or may not occur until after qualification, when

experiences of working in one particular area have influenced decisions

about what roles an individual will seek to remain in. Respondents who

talked about ‘finding a niche’ often did so while discussing the vocational

nature of their role and the desire to do something to ‘help others’, which

often originated early in their lives. However, some respondents

acknowledged having reached this point later in life, having had careers in

different, unrelated fields. At least one respondent had been through some

experiences with family members that had persuaded them to enter a

H&SC profession and ‘give something back to the system’ (NHS14).

Narratives of professional role that suggest it arose through convenience or

through a series of circumstances that did not involve a deliberate choice

are interesting in that participants had not always planned to achieve that

specific identity. There was nothing different about respondents who

developed these narratives, and certainly no difference between them and

other respondents in terms of how much they advocated their professions

or the importance they placed on effective collaborative practice and

patient care. These findings therefore serve as a reminder that each story

about ‘becoming’ a professional is individual and different, but that this

does not necessarily have an impact on the care or education each

individual strives to provide.

209

Figure 6.5: Common narrative elements in describing professional

roles

Professional role

as finding a

niche

When I started my training I thought I was going to

work with children, but as the training went on I really

enjoyed my adult placements…I worked with one of the

best neurologists for stroke and I got into working with

people with degenerative conditions (NHS01)

I first wanted to be a physio…and you start looking

into what goes on in each of the jobs and I felt it was

less what I wanted to do and I wanted to do something

that was more about people and their whole life rather

than just one specific part which obviously for physio is

the muscle mobility (NHS13)

Professional role

as convenient

I chose psychiatric nursing essentially because we lived

near the local psychiatric hospital so it was easy to do

the training (NHS07)

My decision was influenced by economics and personal

situation rather than through career choice (NHS08)

Professional role

as not a

deliberate

choice

I don’t really know how I got into pharmacy other than

my dad was an industrial chemist and I liked my

sciences and I read a booklet…and I came across

pharmacy (NHS02)

Well I wanted to be an archeologist! …I got to a point

where I had to make a decision at A-Levels – I hated

the prospect of A-Level history…biology was a doddle,

so I did not think of not being a doctor, I don’t know

why I just honed into it (HEI11)

210

One respondent struggled with the notion of professional identity; when

asked to describe her professional identity she responded:

It’s not something I’ve ever been asked to do um [pause] are you

allowed to give any clues? (NHS05)

While this is the only example from this study of someone responding to

the question this way, other respondents sometimes struggled to articulate

an answer. This raises the issue of how important it is not to assume that

H&SC professionals are aware of the concept of ‘professional identity’ and

what these identities might mean in, and for, practice.

6.32 Defining moments

During the interviews, respondents often identified what they saw as

‘defining moments’ on their path to developing a professional identity and

‘becoming’ a professional. These were often described without prompts,

although respondents were specifically asked if they had had any ‘defining

moments’ concerning their professional identity if they did not

spontaneously mention them. The most common theme in these

discussions concerned respondents identifying a time when they needed to

take responsibility for tasks they had not previously done. Often this was

during, or just after, the point of graduation:

When you qualify…you have got the skills to do the job and I think

perhaps going onto the ward on the first day is probably one of the

most frightening experiences in your life but people look at you and

you’ve got a badge on that says ‘physio’. (NHS06)

I think the first person that broke down on me when I was sitting in

their living room, and they had become vision impaired…it really

was that moment that I found my career. (HEI12)

However, some respondents identified as a defining moment periods

during their training when they had felt a greater responsibility:

211

[There was] some intense patient contact you know, there were less

junior doctors around and being a medical student was much more

of an apprentice model, and the patients are all telling me this and

will let me stick needles in them and this sort of thing – they must be

taking me fairly seriously. (NHS04)

We were left in charge of wards at the beginning of year three – I

suppose it was being given that responsibility you know you had

to perform and you had to achieve and you had to be seen to do

that. (NHS07)

As both these respondents explained that they had trained some years ago

and believed that such responsibility was not given to students now, it may

be true that these are identical experiences for younger respondents who

identified moments of responsibility that coincided with graduation /

registration.

For others, ‘defining moments’ were associated with the responsibilities of

working in a multi-disciplinary team and a realisation about their

contribution:

Well there’s the first time you diagnose someone with MND –

Motor Neurone Disease…and that happened a couple of times

where you were going down one route and the doctors were going

down another….and realising that your assessment can contribute

to the overall management. At the time I thought ‘this patient’s not

a stroke, it’s something else, I need to let the doctors know’. (NHS01)

In an IPE day, a lady service user came to talk to us about her

daughter…She said ‘you all need to work together for my daughter

at the end of the day, I don’t care how you do it but you need to work

together’ and for the first time I thought ‘now how would I deal with

her daughter? What would I do and how would that interact with

what other people are doing’ and I think that was the first time I

really thought ‘oh god yeah I’m a dietician now and I really need to

think about what I am doing for this person’ (NHS14)

212

These responses are interesting in the context of ‘interprofessional

responsibility’, which for these participants already appears to be a

conscious part of professional identity. Most importantly, it is possible to

see that responsibility towards working effectively with other professions

is associated with doing what is best for the patient. The key question

arising from this is how to most effectively establish such an identity and

associated attitude in student H&SC professionals, and to understand

whether this can be done via, or with the help of, IPE.

One other recurrent ‘defining moment’ of interest was the observation by

many respondents that ‘becoming’ a professional was associated with

putting on a uniform or an item associated with it:

I know exactly where it did happen, and that was at graduation,

when my parents had got my College of Radiographers badge and

they gave it to me then, and then that sort of said to me ‘right now I

belong, now I am a radiographer’ and it was a bit, it was quite an

overwhelming thing actually, but I don’t think until then I’d actually

got that ‘professional identity’. (HEI13)

In the days when I was a student nurse you used to wear uniforms

in the classes. That dates me doesn’t it? But you did, and I

remember the first time I put a uniform on was probably day 1 or

2 of the course, and I remember feeling physically sick at that point

because I didn’t know what I was expecting. (HEI10)

For one respondent, being unable to wear a uniform they felt they had

earned was problematic, because this denied them confirmation of their

identity and subsequently how they viewed their role:

…because my first job role was private sector and wasn’t

technically a bread and butter OT role I kind of had to justify a lot

more how it linked in, so to actually put on the uniform and to get

the first job in the NHS and to wear a badge that says ‘Occupational

Therapist’ suddenly I thought ‘I’m here, I’ve done it and I’ve got the

job’ but I was using all of the skills before. (NHS13)

213

The idea that for some H&SC professionals, uniforms or items associated

with them can be interpreted as symbols of legitimacy to practice fits in

with findings from earlier studies (Spragley and Francis 2006; Timmons

and East 2011). As identified in Chapter Two, the consequences of the loss

of ‘obvious signifiers’ of all professions are unknown, and it may be that

there are perceived threats to identity when professionals feel they are less

easily recognised by sight. However, it may also simply be true that in

being unable to wear items they feel they have earned, professionals feel

they have lost part of their identity they would like to retain:

…green is the OT colour and the trust that I work for did a survey of

all the patients and decided that they didn’t care what colour people

are wearing or what the uniform was they just wanted to be able to

tell what level you were…so we all wear blue, all the healthcare

assistants, nurses, therapists, all wear some form of blue. I feel like

I’ve been stripped of my identity a bit because I don’t get to wear my

green – as much as I hate green, it’s awful! (NHS13)

Physical identifiers such as uniform, badges and even colours therefore still

play an important role in self-perception of identity for some H&SC

professionals, with potential consequences for how professionals believe

they can ‘play their role’ without something they consider an inherent part

of it.

6.33 The ‘academic’ identity

In addition to narratives identified above concerning professional

identities, and defining moments that occur in reaching those roles,

academic staff also presented accounts of how and why they had chosen a

career in teaching. Again, there were similarities between some of these

narratives, with three identifiable themes emerging; the calling to teaching;

the wish to become an educator because of (a) good role model(s); and

chance. Examples of each of these narratives can be found in Figure 6.6.

214

Figure 6.6: Common narrative elements in describing reasons for

becoming a H&SC academic

The

calling to

teaching

In the back of my head I think I’ve always had that I wanted to

be a teacher…in the sport I play I always end up taking the

coaching qualification so that facilitation of learning is always

something I’ve done. (HEI08)

I very much wanted to do the teaching although I very much

wanted to be an audiologist, I was drawn by two callings

(HEI17)

Good

educator

role

models

Well very early on when I started my nursing training I

realised I wanted to go into education…I think I had a

particularly good role model in one of the lecturers (HEI03)

I had an exceptionally good clinical tutor and she actually

asked me right at the very end where I saw myself in ten years

time…I said “in ten years time I want your job” (HEI13)

Chance As always it’s opportunity…at the time pre-reg nursing was

only at Diploma level, I was the only one in the county that had

the Diploma so I was approached (HEI01)

I’d love to say it was planned, you know it wasn’t I just drifted

from one thing – I didn’t drift but opportunities came along

and I was just in the right place at the right time (HEI02)

Teaching was a serendipitous thing. On the day I got my first

psychology degree I was offered some lecturing and thought I

would have a crack at it instead of going straight back to

clinical work and it snowballed from there. (HEI06)

215

Accounts given about why people had gone into teaching were sometimes

coupled with expressions of desire to do ‘something more’ than practice.

HEI01, for example, discussing the completion of a Diploma course, stated ‘I

knew I couldn’t go back to just being a community nurse’. There was,

however, no suggestion from participants that they had chosen to teach

because they did not want to remain in practice (and indeed some

academic participants still did practice). Indeed, when considering their

own identity, the lack of opportunity to practice was seen as problematic

for some respondents:

I see myself more as an academic than a social work identity, and I

struggle with that because I remain proud to say I am a social

worker and a registered social worker and a qualified social

worker, but the reality of my current role is that I no longer

practice…I think my identity is vague and mixed (HEI14)

For NHS staff, many of whom also claimed that a major strand of their

identity concerned being an ‘educator’, the fact that they still practiced was

seen as legitimising their position as someone able to teach:

I do quite a bit of work in that area [mental health], and I do some

in hospital to ensure my practice is up to date. Because I’d lack a

bit of credibility otherwise I think. (NHS07)

For some academic and NHS staff, a lack of opportunity to practice in their

chosen profession was therefore seen as problematic for both the

perception they had of themselves as professionals, and their credibility to

teach students of that profession. The fact that many respondents had not

actively chosen to go into teaching (but had rather done so because

opportunity had led them there), coupled with survey results suggesting

that academic staff might view themselves as either educators or a mix of

educator and the profession in which they had qualified, renders the

professional identity of academic H&SC staff a interesting one for further

study. In particular, it could be questioned whether a lack of current

practice causes tensions between the way NHS staff perceive academic

216

staff, and the implications this might have for both teaching and the

socialisation of students.

6.34 Socialisation

Unsurprisingly given the topics being discussed, the theme of ‘socialisation’

was very prevalent in the interviews. There was a great deal of

acknowledgement of the idea that the majority of professional identity

formation occurs in placement settings, with respondents recognising that

this was the case for their own professional identity and also for present

students. There was also recognition of the idea that the majority of

learning about the roles of other professionals occurs on placement /work

settings.

Learning about roles of other professionals happened more on

wards than in the classroom. (NHS10)

You get professionalised as you train. As you go on wards you see

people that you do want to be like and people that you don’t want

to be like. (HEI05)

I think people get socialised into the sorts of requirements of the

profession, so irrespective of what kind of stuff we are doing in the

classroom when they get into practice settings they are going to

mix with people that are there – their professional group. (HEI02)

Such opinions fit with Pollard’s (2008) observation that role-modelling is

an important part of the ‘hidden curriculum’, and that non-formal

processes involved in learning behaviours occur regardless of whether

observed behaviours are desirable (Cheetham and Chivers 2005).

Certainly the ‘dangers’ of the wrong message reaching students through

socialisation were apparent in some responses offered:

217

I think any epistemological belief you have about your own

profession or anything personal - your students will pick it up. It

becomes part of their belief system. (NHS07)

Being an OT they drill into you from the start that nobody knows

what we do. (NHS13)

With such a high level of recognition that work-based experiences are

important to both the identity-formation process and in learning about

other professions, some respondents questioned whether those

responsible for H&SC education should emphasise these issues to students,

making more of work-based experiences than they currently do:

I think integrating IPE as part of training would help break down a

lot of barriers. I think once you get engrained in that then

everything you see reinforces that idea. The earlier you can

reinforce a different kind of thought pattern the better. (NHS12)

One of the challenges is influential colleagues who are ‘old school’.

Maybe it’s about bringing in people who have been in challenging

interprofessional services into education rather than trying to get

some of the ‘old school’ giving the wrong messages. (HEI04)

These suggestions fit well with the concept of ‘interprofessional

responsibility’, ensuring that staff both think in such terms and can ‘model’

such behaviour to trainee members of all professions who may observe

them.

6.35 ‘Strength’ of professional identity

After describing their professional identity, respondents were asked if they

felt if they had a ‘strong’ professional identity. Many claimed that they did

so, mainly because they viewed their profession as part of who they are, or

because they were passionate about it:

218

It’s a part of who I am because I feel like I’ve been doing it for so

long, and I’m really passionate about being a speech therapist.

(NHS01)

For academic staff in particular, values associated with their professional

identity were perceived as being entrenched in ‘part of who they were’:

I’ve often thought – ‘no I don’t think about myself as a learning

disability nurse’, and then I’ve kind of been aware that it’s just

become part of the taken-for-granted me, for example part of the

learning disability work is about being politically conscious of the

words that you use, the language that you use, the way that you

interact with others, and I find that that rolls out in every part of

my life… (HEI01)

I still see myself as a doctor and I still think about practice as a

doctor, I don’t mean clinical work because I gave that up but I think

you know the ethics, the morals and all those types of things, those

are still important (HEI11)

There was only one respondent who expressed negative opinions about

her professional role and identity. Describing her own profession as ‘a bit

of a waste of time’, she felt that because interventions she and colleagues

started did not instantly solve problems, people referred to them only as a

‘last resort’. Her thoughts about her profession also appeared to be related

to a belief that other professions did not know what they did (although, as

explored in Section 6.4, this respondent was not the only person to express

this concern):

My identity is vague…as a dietician, people think you are an SLT, or

someone with menus asking what food they want…I get a lot of

questions professionally about what comes under my role.

(NHS15)

The participant suggested that part of the way she felt about her

professional identity related to never having long term contact with

219

patients; her team offered what they could to patients while in hospital but

it was likely that, once discharged, they would never see them again or find

out the outcome of interventions they had put in place. This, she reported,

made her feel that her profession was ‘a bit useless’, despite admitting that

these feelings might change if she was in a specialist team. This illustrates

how professional identity can be context specific, an issue explored in more

detail below (Section 6.36). While this was the only example of very

negative views about a profession, it highlights that it should not be

assumed that H&SC staff will always be advocates for their profession, and

that this might be problematic for the socialisation of students into

particular professions. As survey results indicated that the majority of staff

have at least some contact with students on placement, consideration must

be given to how to prepare students who might encounter such negative

views, even if these are rare.

One final noteworthy strand about participant’s perceptions of the

‘strength’ of their professional identities concerns reference to seniority of

status. Staff more recently qualified reported that they did not yet have a

stable professional identity, which they ascribed to the rotational nature of

their roles. However, there was also recognition among these participants

that they would achieve a more stable identity once they held a more

permanent role:

I think because I’m a junior member of staff and as I said a

rotational member of staff at the moment my identity fluctuates and

changes quite a lot – I suppose you are a bit of a chameleon at this

stage in training…I wouldn’t say I have an allegiance or that this is

where I see myself going as a specialist… (NHS12)

Talking more generally about the concept of professional identity (rather

than specifically about their own), other respondents echoed these

thoughts about senior status and identity:

I think the more senior you get the more people acknowledge your

professional identity. (NHS09)

220

I would imagine [that] as you get more senior and you have more

influence that you would feel even more that you had some sort of

stronger identity. (NHS13)

The idea that professional identity becomes more secure with experience is

not that surprising (and many respondents acknowledged that their

identity had changed over time and continued to change). However, when

combined with results from the survey suggesting that H&SC staff engage

more effectively with the concept of collaborative practice as they become

more experienced / senior, it could be claimed that those with more secure

professional identities are better able to work collaboratively. This may be

because they feel less threatened by the concept of interprofessional

collaboration and / or better understand how working in this way

improves patient care; they may acknowledge the responsibility they have

to work in this way. Again, an important consideration arises concerning

how something which appears to arise from experience can be ‘taught’ to

student and young H&SC professionals.

6.36 The intra-professional identity

One theme emerging from the responses of interviewees about

professional identity concerned ‘intra-professional’ identity. That is, rather

than ascribing themselves (or others) an identity aligned with a particular

profession, many associated themselves with a sub-unit of a profession,

either a particular branch or specialty. This was often accompanied by

claims for uniqueness of the branch to which they were aligned

themselves:

...a big part of the professional identity for me has been a learning

disability nurse and I think that is quite unique within the family of

nursing and also within the family of health and social care and I’m

quite happy to describe myself as a learning disability nurse…I

think that it brings with it um, a certain set of values and attitudes

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that I’d like other people to think I would have as a nurse and

personally as well. (HEI03)

The broad professional identity would be doctor err and then

within that I think there would be anaesthetist because it’s a fairly

large subgroup. (NHS04)

It depends who I’m talking to, um, well as a group we call

ourselves specialist midwives so I suppose that’s how I think of

myself. I still think of myself as a midwife but that I specialised in a

slightly different role to most other midwives. (NHS09)

The fact that H&SC professionals are often likely to align their identity to an

intra-professional identity (as opposed to a whole-professional-identity)

raises questions for both the future study of professional identities and for

IPE. Professional identities in H&SC have typically been described and

studied through over-arching professional labels; this may be unhelpful in

understanding professional identity and its implications if this is not the

way that professionals themselves perceive their identity. Intra-

professional identity also has implications for the conceptualisation of IPE.

On this topic, many respondents commented that their branch of a

profession was more closely aligned to branches of other professions

undertaking similar roles. For example, one respondent working in child

social work said they felt more professionally aligned to child nurses and

learning disability nurses than they did to adult social workers (HEI14).

With this conceptualisation of professional identity, it can be asked

whether IPE should be thought of as something that needs to occur

between branches of professions. Alternatively, if they do not usually work

together, IPE might be about ensuring specific branches of professions have

opportunities to learn and work together, ensuring that students

experience the most relevant situations.

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6.37 Professional identity as context specific

One final noteworthy theme concerning perceptions of professional’s own

identity related to the way it was often viewed as context specific. As

already mentioned, for the respondent with a negative opinion of her

profession and identity, there was acknowledgement that this might

change if her job situation changed and she worked in a different

environment. Another respondent reported that the way in which identity

was context specific related to who else was available in the team at any

time:

…when I am on nights I am the only person of my grade covering

everything…so in that respect I am an integral sort of the team and

very much needed, but then on another day if I’m on the ward I’ll be

one of let’s say five people at a similar grade, so it really varies how

and where you are in the teams. (NHS12)

For another respondent, identity concerned differing job roles and people

involved:

I think my professional identity has changed over time because of the

job roles, because I’ve left front line nursing it has become different

because I’m dealing with a different group of people. (NHS07)

For another, the notion of a professional identity being context specific was

related to the concept of the intra-professional identity:

I don’t think the profession as a whole [has a strong professional

identity] because it is so varied in terms of the different areas and

departments because an OT working in social services would be

completely different to an OT working in forensic mental health for

example, you know so that vast difference makes it very hard - in

essence OT has a professional identity in each area. (NHS13)

Such views fit in with the notion of identity as fluid, but also suggest, as

Lawler (2008) describes, that identity is not ‘foundational and essential’

but is produced through the narratives that individuals use to understand

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their lives. The findings here also imply that being a member of a

profession does not result in a shared group identity which is understood

to be the same by all members, even when the identity of being a member

of the profession is earned only via similar training processes and the need

to meet identical standards; a finding which mirrors the earlier work of

Machin et al. (2011) into the identity of health visitors. In this study, this

appears to be due to the complex ways in which health and social care

professionals work; therefore conceptualisations of their identities are

associated with a specialty, a certain client group, the physical location or

the team within which they work. This means that for many H&SC

professionals, even their ‘professional identity’ can change from one

moment to the next.

6.4 Conceptualisations of the professional identities of others

In addition to perceptions H&SC staff have of their own professional

identity, this thesis is also interested in exploring conceptualisations staff

have of the professional identity of other professionals. The research

explored this by asking two key questions concerning the identity of others,

the first being: ‘do you think that some professions have a stronger identity

than others?’ Responses to this question were unsurprisingly varied, with

several different professions identified as having strong identities.

Interestingly, however, these were rarely the respondent’s own profession.

I think nursing has got a very strong one…they can very quickly

identify that this is not nursing or this is nursing.

(NHS06 – physiotherapist)

Medicine very much so and I think professions aligned to medicine

you know occupational therapy, physiotherapy particularly are

very strong. Nursing I never really felt as being truly strongly

professional um I think it was sort of more because it was an

apprentice training and they had to fight to say ‘we have a

professional identity’. (NHS07 – nurse)

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I do think probably OT does have the least professional

identity…because no-one outside the profession really understands

what we do so that can either make you really strong in what you do

or water it down and kind of become more generic working…

(NHS16 – occupational therapist)

There was an observable process of ‘othering’ in responses to this question,

where a ‘strong identity’ was often viewed as something other professions

had, but not commonly claimed for a respondent’s own profession. As

highlighted in the final quote above, the lack of a strong professional

identity for one profession (or a stronger identity in another) was often

associated with the perception that others were not able to identify what a

certain profession does:

I honestly don’t think that doctors know what we do…again I think

because OT is so different in so many different areas I makes it

difficult for people to understand…I think what happens a lot of the

time is that they see somebody and they think they need to be seen by

a physio their mobility is terrible and they just go ‘oh if they are

seeing a physio they better see an OT’, but they don’t really know

where we come in and from an OT point of view you think ‘well what

do you want me to assess?’ (NHS13 – occupational therapist)

This ties in with the findings of Machin and Pearson (2013) who noted that

a lack of awareness of the health visiting role hindered the potential input

of health visitors into interagency teams (p36). The quote here also

reinforces the notion that intra-professional identities change according to

context, and highlights that for some professionals, their perception of

other professions is based on the largely negative opinion that members of

other professions do not understand what they do. For other respondents,

strength of their own profession’s identity, or that of another profession,

was based on whether they believed members of the public understood

what they did:

I do think that people don’t know about speech therapists so it

keeps us under the radar - you know there are pros and cons to

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it…so you know, nurses have a hugely strong identity, and you can

see why, you know I think they’re brilliant, amazing people, I could

not be a nurse, but you know you never hear of anybody going on a

march saying ‘we need more speech therapists or we need more

occupational therapists’. (NHS01 – speech and language therapist)

Where IPE might make a difference in addressing concerns that

professionals should be able to identify each others’ roles (thus potentially

strengthening one element of professional identity), little can be done to

address a perceived weaker identity that arises from a lack of public

knowledge about what each H&SC profession does. Many respondents

reported that the public understood what they did only if they had had

personal experiences or encounters with a profession, and that as such

they were most likely to understand the roles of doctors, nurses, midwives

and pharmacists.

The second interview question directly related to exploring H&SC staff’s

perceptions of the professional identity of others asked ‘are there some

professions you find it easier than others to work with than others?’ Many

respondents felt that finding someone easy to work with or otherwise was

less about professional backgrounds than individual personalities. For

others, however, a perceived relationship between their own profession

and another meant that they commonly considered these other groups

easier to work with:

Speech and language therapists because we are so closely

associated in what we do…we have an affinity perhaps more

naturally. (NHS14 – dietician)

I think maybe physio just because we kind of do work closely

together…I’ve never had much cause to work with radiography.

Speech and language therapists I’ve worked with a little bit when I

did learning disabilities I did find them easy to work with, they are

kind of working towards the same goals.

(NHS16 – occupational therapist)

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Probably nurses and midwives…because I can make reference to

them, but having done critical care it is not too difficult to talk with

the radiographers because you worked with them all the time

anyway. (HEI06)

Similarly, respondents who named certain professions as harder to work

with recognised that this was mainly because these were professions with

whom they had very little contact, because of either their job role or

organisational structure:

There are professional structures and when one particular

profession dominates the structures within an organisation,

maybe it is the organisation that becomes difficult to work with

(HEI04 – occupational therapist)

…only because I don’t come into contact with them that much so

consequently I probably know less about them but I wouldn’t say it

was any barrier particularly only a bit of an unknown factor. For

instance I don’t really have much contact with physiotherapists or

occupational therapists. (NHS08 - pharmacist)

From a nursing perspective it’s probably much easier to work with

ward based professions than people who come on the ward and do

their bit and off they go. (HEI05 - nurse)

These reflections raise a number of issues concerning professional identity

and IPE. In the first instance, finding some groups of professionals easier

than others to work with (because of having previously worked with them)

relates to the idea that effective collaborative practice is learned through

experience and not easily taught. Secondly, it can be questioned whether it

matters if some professions are perceived as easier than others to work

with on the basis of being closely related in job role. If professionals are

unlikely to come into contact with one another, such perceptions will have

little impact; similarly, if contact with other professionals is only

infrequent, it seems unlikely that such perceptions will change. This raises

a significant question about whether IPE should focus only on bringing

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professions together who work together in practice (i.e. as being the most

relevant experiences). Providing relevant IPE was certainly identified as a

recommendation of the common learning pilots (Miller et al. 2006) and has

remained a theme of much literature since (Anderson and Thorpe 2008;

Rosenfeld et al. 2011).

Finally, there were some views of professions who were perceived as

easier than others to work with, not based on anything other than a

judgment about professional differences:

Social workers were the ones I found very difficult to work

with…that’s probably my prejudices, I found the ‘how is this for

you?’ round the houses approach very difficult to cope with but I

would say that is more a sad indictment of me than of social work.

(NHS07 – nurse)

I’ve always found health visitors a bit odd but er that’s just me, I

don’t know whether health visitors are picked from the cradle,

that’s just a joke aside. (HEI02 – nurse / midwife)

These comments are related to the final theme in this section: ‘negative

perceptions or stereotypes of other professions’. These were not responses

that emerged as a result of a specific question, but rather comments made

about other professions during the course of interviews which were

surprising in the context of discussions around interprofessional education

and collaborative practice. This occurred more commonly in interviews

with academic staff members than with practicing staff, which may reflect

the fact that I knew or had previously met many of the academic

respondents and that this meant that they were more comfortable

expressing negative views to me than the NHS respondents who had not

met me previously. Nevertheless some examples of such comments

emerged from across the range of interviewees:

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The doctor is still king and if he isn’t then he still thinks he is.

They’ve maybe come down a peg or two to a lower prince.

(NHS3 – speech and language therapist)

I don’t think physios have ever struggled [with their professional

identity] I think physios just fix bones and muscles don’t they? I

think nurses have become confused, she says in an opinionated

way, I think the role of nursing has really really changed um and

are they now pseudo-doctors? Are they, I mean in some settings

certainly medical health they are trying to be OTs as well, they are

running the groups, they are doing the occupational therapy bits

without the training or understanding how to do that…and then

social workers sort of know what they do. They’re just bank

managers aren’t they? (HEI08 – occupational therapist)

In this example, it might be claimed that concern over professional

boundaries relating to nurses taking on aspects of an occupational role is

justified if concerns exist that they have not been properly trained to do so.

However, comments made about other professional groups are relatively

unnecessary.

Um you know there are different nuances with different

professional groups, I always think that dieticians are quite picky,

speech and language therapists are – I hate to use the word anal,

very attention to detail type thing, I think physios have a broader,

you know a broader view of things generally and OTs tend to be

very particular. Um but you know there are different ways of

working. I find it easier to work with AHPs than I do with nurses.

(HEI09 – dietician)

As these comments were made by a dietician, it would seem unlikely that

they were intended to be negative per se, but the concern is that if they are

expressed to students, they could result in students holding unfair and / or

untrue opinions about professional colleagues. Despite all respondents

being aware of IPE and its principles, and many having been involved in

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interprofessional initiatives, it appears that there is some distance to go

before perceptions of professional identities are seen always as less of a

barrier to collaborative practice.

6.5 Experiences of IPE

While experiences academic staff had of being involved in attempts to

implement a large-scale interprofessional programme of work were

explored in Chapter Five, this research was also concerned with staff

experiences and perceptions of any IPE they had received themselves. To

facilitate exploring this, the interview included a question about whether

IPE had been part of respondents’ professional training at undergraduate

level. As with the survey respondents, experiences were mixed, and not

many could remember having had received anything formally called (or

assessed as) IPE. Of those who could remember IPE, only two spoke

positively of their experiences:

We had a two-week placement on an IPE ward. That was actually

really good because it’s quite nice having a chat with other students,

um we were all at a similar stage in our training, coming up to the

end but none of us were quite there yet (NHS12 – doctor)

However, this respondent went on to explain that this placement had since

been stopped and that, while he had enjoyed and found it useful, many

colleagues had complained about having to do it. He reflected that students

get out of it what they put in, and believed he was lucky to have joined a

group that was committed to benefitting from it. Respondent NHS13 also

expressed positive thoughts about IPE received during her undergraduate

training:

I had a placement on an interprofessional training ward…you got

to understand what other people’s difficulties were in their own

roles which meant you could think about how to help them…but I

only got to do it because I found out about it. So I had that

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experience but there were about 80 or 90 people in my year.

(NHS13 – occupational therapist)

Respondents’ positive IPE experiences were therefore somewhat limited.

More respondents reflected on IPE experiences that had had a more

negative impression:

We had one day where we mixed…there was probably like a token

dietician who said ‘this is our role’ that was it, there was nothing

about how do we work together.

(NHS01 – speech and language therapist)

We all hated communication skills – we had to do role-play but it

wasn’t relevant and the scenarios were contrived.

(NHS16 – occupational therapist)

Even one of the respondents who had spoken of positive experiences

suggested that not all university-driven IPE was effective:

Some of the things at university did seem really false and just

exercises, more tick-box, you know? (NHS12)

For a couple of respondents, negative experiences of IPE were associated

with the way in which members of their groups failed to engage with the

task. NHS14 described how, in small interprofessional groups, they were

expected to watch a video and then discuss it together; however, other

members of her group had just wanted to sign the form to say they had

participated even if they had not. She found this frustrating and had to

argue to get them to undertake the task. Similarly, NHS15, who attended

large-scale IPE days at her university, had had someone allocated to her

group whom she considered unprofessional; consequently she was ‘put off

the concept of IPE completely’. Nevertheless, even when respondents

described personal negative experiences of IPE, they remained positive

towards the notion that IPE could improve team-working and, ultimately,

patient care. No single respondent claimed that they did not feel it could

achieve such aims, although many said that they only ‘hoped’ IPE could do

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so. There was, however, no sense in which negative personal experiences

of IPE had led to a negative perception of IPE in general. This may be an

effect of the self-selecting nature of respondents, many of whom may have

felt positively inclined towards IPE to take part in a study looking at it.

However, the fact that negative personal experiences did not seem to lead

to negative opinions about the possibilities of IPE is worth noting, and

mirrors the findings of Rosenfeld et al., who, as was discussed in Chapter

Three, found that despite their respondents’ recollections of their first IPE

experience being largely negative, still felt that there was ‘value and merit’

in IPE (2011, p474).

Many respondents reported that they had not received IPE as part of their

undergraduate training because they had trained at a time before IPE was

conceptualised as it is now. However, many felt that interprofessional

working was part of placement learning and was a requirement of the

course:

What existed would have been on placement.

(NHS03 – speech and language therapist)

There was no IPE, it was 1975! Interestingly we did have good

interprofessional working [but] nobody had invented that term yet.

(HEI02 – nurse)

When I was a student you had working with other people as a

learning outcome, you had to pass a placement, so that’s massively

embedded. (HEI04 – occupational therapist)

The extent to which the academic concept of IPE has ‘replaced’ something

that was previously informally learned on placement was not a topic raised

in interviews. Nevertheless some responses suggested that the most

relevant strands of placement-based IPE, that are proposed today as best-

practice, happened anyway as part of training which was more – and in

some instances, entirely – ward-based. The extent to which this has been

lost through moving healthcare professional training into universities is an

interesting issue for debate, but also raises questions about whether there

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remain many excellent IPE opportunities occurring in placement settings

that are ‘missed’ because they are not flagged as IPE. This in turn raises

questions about whether IPE is merely an academic label for something

which has always been a fundamental part of H&SC professional education.

Finally, it is worth noting that in addition to experiences of IPE as students,

some staff also had experiences of facilitating IPE (in addition to that

discussed in Chapter Five as part of the ALPS programme). In line with

existing literature, many respondents identified the organisational barriers

to implementing IPE, including difficulties of time-tabling across large

cohorts of students and negotiating time within already busy curricula to

incorporate IPE events.

Only two of the NHS respondents had experience of facilitating IPE, but

both expressed positive views about the perceived impact sessions they

had been involved in had on students. Similarly, academic staff, who

described a number of different IPE initiatives, from one-off annual days to

trans-disciplinary first years, were all positive about the potential

outcomes of IPE experiences they offered students. As one respondent said

when asked if they believed that IPE would make a difference to the way in

which health professionals think about their professional working

practices:

I’m hoping it will I suppose – I must think so otherwise I wouldn’t be

spending so much time on it. (HEI06)

Many respondents were pragmatic about their institution’s approaches to

the provision of IPE, as illustrated by this quote from respondent HEI04:

The first thing to understand is that things go in a circular, so we

had IPW [interprofessional working] as a module, the evaluation

would always then show that it would be better if it was threaded

through the whole curriculum, so the next time we revalidate we

spread it through the whole curriculum, somebody will come up

with the bright idea that it would be better if you can consolidate

it. I think that is driven by different learning styles – so you will

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always have the students whose learning style is not met who say it

would be better if we did it the other way…I think the whole issue

about being seen to do it rather than being trusted to do it drives us

towards a more reductionist approach. (HEI04)

The notion that benchmarks from regulators drive policy concerning the

provision of IPE meant that, for many academic respondents, the notion of

‘ticking the box’ and being seen to be doing it was the most important

factor in its provision. While this is not intended to suggest that effort does

not go into providing IPE, there was a worrying undercurrent in academic

responses suggesting that the provision of IPE was often more about

paying lip-service than concentrating on changing working practices, either

for students (future graduates) or even themselves. Respondents HEI14

and HEI15, for example, from the same institution, spoke of their

profession being excluded from interprofessional initiatives because their

department had been moved out of a building they had previously shared

with other H&SC professions; the implication was that moving out of the

same physical location had meant it was no longer relevant for their

students to have opportunities to work and learn from students of other

professions. Positive attitudes towards the potential for IPE to make a

difference, and the recognition that this needed implementing in a relevant

way, did not always seem to fit with practices described about the way in

which IPE is designed and implemented.

6.6 Collaborative practice

Respondents spoke about collaborative practice at many points during the

interviews; three themes emerged concerning their reflections of working

in practice across professions.

The first is called ‘collaborative practice occurs anyway’ – that is, without a

specific interprofessional initiative or IPE. When asked which elements of

their roles could be described as ‘uni-professional’, academic staff

sometimes spoke of teaching they gave to one specific profession; however,

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both academic and NHS staff often struggled to think of any elements of

their roles in practice they would describe in such terms:

Everything we do is interprofessional, you couldn’t work by

turning up and doing things on your own…this includes admin

staff. (NHS12)

On the stroke ward at the hospital it was so evident that everybody is

a piece of the jigsaw and without all the pieces coming together the

person is not going to rehabilitate. (NHS14)

When I think about my GP practice and the way they work together

– so it was ever thus. It feels a bit like emperor’s new clothes to me

sometimes (HEI2)

The idea that the majority of work in practice involves a collaborative

element – and has done for many years – again raises a question about the

extent to which ‘interprofessional education’ is an academic interpretation

of something that must occur anyway.

Related with this is the second theme from this data, which concerns the

extent to which being able to collaborate effectively in practice is

something that is learned through experience. This ties in with survey

results presented earlier which showed that senior members of staff were

more comfortable working and communicating with members of other

professions than their junior counterparts. Some respondents spoke of

difficulties involved in capturing this experience for students:

I think the challenge it to harness it – to capture it on a day-to-day

basis. (HEI05)

It’s not that they don’t get exposure I just wonder whether we are

not capitalising and using that and students need a lot of help

signposting, that kind of thing. (HEI02)

We could teach students for years and years and years, what we

can’t give them in the classroom is experience. (HEI15)

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It comes through experience…knowing where to ask for help

(NHS06)

Others discussed the fact that effective collaborative practice occurred

when people had worked for a long time in the same team:

It’s about being able to put a face to a name – that breaks down

barriers…Familiarity and trust come as a gradual thing. (NHS09)

Nurses pick up on how different doctors conduct their ward

rounds, but it’s informal and learned through observation.

(NHS11)

These issues clearly pose considerable challenges for the conceptualisation

of IPE as a separate initiative – that is, it is impossible to teach anything

which is only learned by experience. However, if the concept of

‘interprofessional responsibility’ was incorporated into H&SC training and

into the identities of all H&SC, it may be true that this would prepare

students in more consistently for these experiences.

This discussion also ties in with the theme identified in the literature

concerning the ‘right time’ to introduce IPE. Anderson and Thorpe (2008)

concluded that younger IPE participants appeared to gain the most from

early IPE initiatives while Thistelthwaite (2012) argued that there was no

reason to delay IPE once professional training had started. This ties in with

the thoughts of the participants in this study; the vast majority of whom,

when asked about the ‘right time’ to introduce IPE, suggested that it should

be taught at least as a concept from ‘day one’. A few respondents however

did recognise that it was particularly difficult to identify the ‘right’ time:

I have thought about that but I am not sure whether there is a right

time...if you introduce it at the beginning…you change people’s

concepts and ways of thinking straight away, whilst the argument

is that if you so not know much about your own profession how

are you going to understand how the other profession works?

(HEI05)

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Such dilemmas may be solved by the introduction of the concept of

‘interprofessional responsibility’ was incorporated early into H&SC

training, leaving that which is potentially more ‘easily’ learned through

experience to come later when students are better prepared for it.

The third interview theme, which relates to points raised above, concerned

perceived ‘missed opportunities’ for collaborative practice, or missing

opportunities to introduce the concept to students.

When we are on the wards we work very closely with physios but

not as closely as I’d like – there is a lot of duplication. (NHS16)

If you don’t introduce IPE in day one they become established in

friendship group and then IPE gets introduced as something

different. I think we’re setting ourselves to alienate students

against it. (HEI01)

This is important as it recognises that, despite many respondents

identifying areas of effective collaborative practice, there is a still work to

be done in addressing areas of role-duplication and perceived barriers

caused by professional identities while working together. The next section

explores in more detail respondents’ reported perceptions about the

relationships between professional identity, IPE and collaborative practice.

6.7 Professional identity, IPE and collaborative practice

During interviews, there were some instances where the way professional

identity and IPE or collaborative practice are directly related were

discussed. The first emerged as a theme from responses to a number of

questions – namely, that ‘professional identity can be a hindrance to

patient care’.

Students get introduced to the concept of the MDT [Multi-

disciplinary team] but often then get told ‘but remember you’re a

nurse’. Loyalty should be to a patient not to a profession. (NHS07)

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I think in terms of service delivery to shape services around

professional identity is wrong and outdated and I think perhaps

the two things are entangled in a way they shouldn’t be (HEI04)

I think yes, it’s important to remember you’re a professional, but I

think the label of ‘professions’, oh I know radiographers are going

to hate me for saying this, you know I don’t think we should be

locked into these camps. I know a lot of us are probably quite

precious about our professional status but I think it does get in the

way sometimes. (HEI13)

This issue presents a challenge for the whole H&SC sector, and relates to

the way roles are conceptualised and tasks distributed. It may be true that

large organisational change is required for this to occur, that changes are

required which are beyond the influence of IPE initiatives. That this

concern exists for both NHS and academic staff suggests that debates on

the way professional identity is conceptualised must be revisited.

Secondly, respondents were asked directly if they believed that an

increased focus on IPE would change the way people felt about their

professional identity. Only one respondent suggested that people could be

defensive about their professional identity and view IPE as a threat

(NHS06). Some felt that IPE would not make a difference to professional

identity (NHS08); two accounted for this by suggesting that it was because

in practice so many people have an ‘ingrained professional identity’ or are

‘set in their ways’ (NHS07; NHS15).

For the most part, however, respondents were very positive that

professional identities could, or should, change as a result of IPE:

I think IPE does change the way you think about your professional

identity and I think it gives you more knowledge about other

people’s professional identity which is important for the bigger

picture. (NHS13)

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IPE should change the way we think about professional identity,

otherwise we are wasting our time. (HEI04)

For some respondents, their perceptions were less that professional

identities would change as a result of IPE, and more that IPE would result in

what was understood about the roles of other professions:

Part of having an identity is knowing where your boundaries are.

(NHS09)

I think by focusing on it, it makes you realise where you fit into

it all and therefore what responsibility you have not just for your

own learning and professionalism but for those of others, because

others can’t act professionally unless you do your part. (NHS14)

If it is introduced early on whilst learning all those other new things

you just take it for granted and IPE is part of how this profession

works, so it’s not going to be a threat. (HEI05)

Such views tie in with the notion of interprofessional responsibility as part

of professional role. However, academic staff were much more sceptical

than NHS staff about the ability of IPE to make a difference, particularly as

an isolated initiative:

It depends what is going on outside of that and the attitude of people

within the uni-professional elements and the influence that has on

students. I think we just need to keep chipping away at people and

challenging them…to think differently. (HEI01)

I think you’ve got people who will always bang away at that

particular professional identity drum. It’s hard to see how educating

people or how IPE alone would actually make huge strides in it

because of socialisation. (HEI02)

I: Do you think that IPE changes the way that people think about

their professional identity?

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I think that if it’s at undergraduate level not necessarily and I think

you might continue the differences between HEIS and trusts. I think

certainly IPE at CPD level and post-graduate level should help to

reduce some of those tensions but only for that very tiny minority of

people who access post-grad. studies. (HEI10)

These responses relate to many issues explored earlier in this chapter and

in literature about concerns over socialisation processes and their effects.

The difference in conceptualisation between academic staff and NHS staff

over whether IPE could change the way people think about their

professional identity could be related to the fact that NHS staff may think

more about the ‘training’ and ‘doing’ of collaborative practice, as opposed

to IPE as an element of education (however, it is not possible to say this

with any certainty as it was not apparent in the interviews). As already

noted, nearly all respondents suggested that IPE should be introduced

early in the undergraduate curriculum (year one, at least, and many said

‘day one’), but again, academic staff were far keener on introducing the

concept of IPE early, and less convinced that any practical element should

be involved until later in a course. Respondents from across the NHS and

academia stressed the importance for any IPE to be relevant before it was

considered meaningful.

Perhaps most interestingly, attitudes expressed by respondents concerning

IPE and collaborative practice did not seem related to whether or not

respondents had experienced IPE themselves. Many respondents were

positive about the potential for IPE to change the way H&SC students

viewed professional roles and boundaries when they had not experienced

IPE themselves, and some were positive about the potential for IPE to make

a difference even if they had described a negative experience of IPE. The

implications, and of all the findings from the research presented here, are

discussed in the following, final chapter.

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6.8 Summary

This chapter has presented, in as much detail possible, results from the

empirical elements of this study. While it attempted to cover the results

most relevant to the research questions, as well as those most interesting

to arise in relation to topics of interest, it has been necessarily selective. As

with all research of this nature, one limitation to acknowledge is the

researcher focusing certain results over others. Nevertheless the results

presented here are intended to show both the strongest themes to emerge

from the research and a range of participant perceptions on, and attitudes

towards, professional identity and IPE, as well as their views about

relationship between the two. A summary of key findings from this

chapter is presented in Table 6.9. The final chapter, following this one

further summarises the findings of this chapter with reference to the

research questions included at the beginning of the thesis, and then

discusses these in relation to existing literature on relevant topics (as

outlined in Chapters Two and Three). Finally, it discusses implications of

findings from this research and concludes with recommendations drawn

from what has been learned.

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Table 6.9: Key Findings from Empirical Research

Respondents in this study were more likely to align their identity with a

branch or sub-group of a profession than they were with a ‘whole

profession’; conceptualising H&SC professionals as having an intra-

professional identity may therefore be more useful than using whole-

profession labels

Professionals who rated themselves as more ‘senior’ were more

comfortable working across professional boundaries, and there was also

some recognition that professional identity develops with experience and

seniority. It should therefore be recognised that collaborative practice and

confidence in a professional identity are particularly difficult, if not

impossible to ‘teach’; as such educators should look to prepare students to

work collaboratively

All professionals have a responsibility to work across professional

boundaries in order to ensure the best patient care is provided. This can be

conceptualised as ‘interprofessional responsibility’, that can and should be

incorporated into each individual professions’ identity, and introduced to

student professionals as early as possible.

Staff who teach often feel they have a different identity to the one aligned

to the profession that they trained in. Conceptualised here as an ‘academic

identity’, this may have implications for the way in which students they

encounter are socialised into professions, and is an area worthy of further

study

Professional identities are often understood to be ‘fluid’; for H&SC

professionals, identity can depend on context (shift, team-structure,

rotation) which has implications for the way in which students are taught

to think about their identities and the way in which they are encouraged to

adapt to different situations

Negative views of professions, either of one’s own, or others, can have

damaging effects on the way in which students perceive identities.

Negative perceptions of all professions should be avoided as part of the

‘interprofessional responsibility’ described above.

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Chapter Seven

Conclusion: Professional identity in an interprofessional

world

7.1 Introduction

The primary objective of this research was to explore the interrelationship

between perceptions of professional identity and the way in which H&SC

professionals interpret and experience interprofessional education and

collaborative practice. It is important to note that the literature reviewed

as part of this research suggested that evidence that IPE actually leads to

improved cross-professional working remains partial at best, although

there is increasing evidence that relevant practice-based IPE initiatives

improve understandings of the importance and need for collaborative

practice. While this research did not set out to prove that there is a link

between perceptions of professional identity and IPE (and indeed it was

acknowledged that there being ‘no link’ would be significant of itself), the

findings have shown that the way in which professional identities are

perceived can have a substantial impact on attitudes towards other

professions. These attitudes subsequently impact upon attitudes towards,

and likely success of, IPE and collaborative practice. In turn, there remains

a danger that negative attitudes towards other professions that impact on

collaborative practice will result in less than optimal patient care.

Furthermore, where it is staff members expressing negative attitudes

towards other professions (and evidence gathered for this research

indicates that this does happen), it is possible that student professionals

are socialised into finding it acceptable to hold and express negative

opinions about other professions. This ‘learned’ behaviour further

increases the likelihood that IPE and / or collaborative practice will be

dismissed as unimportant or irrelevant.

Throughout this thesis it has been noted that it is impossible to conduct

any form of research without the position of the researcher having an

impact on the analysis of the results. As previously stated, the research

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was conducted under the assumption that it was possible for there to be no

link between IPE and professional identity, however there were certain

assumptions made at the start of the research process which may have

influenced its course. Having worked as part of the ALPS-CETL and being

introduced to IPE in that way, this shaped my initial approach to the

research undertaken here. The research was always concerned with

exploring the relationship between professional identity and IPE, but it was

only during the literature review stages that it became apparent that there

was only a small amount of evidence for the efficacy of IPE. As a result of

this, the way I came to think about the relationship between professional

identity, IPE and collaborative practice shifted somewhat, and

subsequently the way I thought and talked about IPE became much more

about the ‘potential’ for it to make a difference rather than being based on

the difference that IPE does make. Additionally, my own preconception

was that there would be differences of opinion between the professions

concerning attitudes towards IPE. Subsequently the survey in particular

was designed to draw out differences in opinions between professions.

The analysis of the survey results however, revealed very little difference

between professional groups and their opinions (the exception being those

already identified in Chapter Six, concerning the fact that nurses were more

likely to disagree with the statement that their profession is responsible for

tasks that no other profession can undertake, while social workers were

less likely to agree that there was respect between all professionals). To a

certain extent this felt surprising in the context of literature regarding

tribalism and silos. However in relation to the emerging finding of this

research that many professionals have more of an ‘intra-professional’

identity than one aligned to a whole profession, it was on reflection

perhaps not all that surprising that analysing the results by ‘professional

group’ did not reveal that each profession held an identifiably cohesive set

of views and opinions on any topic explored here. This also strengthened

my perception that the concept of ‘intra-professional’ identity was one

worthy of further exploration.

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This final chapter summarises the findings from all the research presented

in this thesis, drawing on both discussions of existing literature and

original data collected specifically for this project. Each key finding related

to the research questions is presented as a statement, followed by an

explanatory summary. The chapter concludes with implications and

recommendations based on the findings, presented in the same way as the

key findings, and suggesting how debates about ‘professional identity in an

interprofessional world’ might progress.

7.2 Summary of Findings

How do practicing H&SC staff conceptualise their professional identity, and

the professional identity of other professions with whom they work or learn?

1. There is no single experience of identity formation, but defining

moments involving responsibility are often important for H&SC

professionals

Literature reviewed in Chapter Two identified difficulties of

conceptualising a ‘group’ identity, in particular where identity is

understood to develop from personal and unique experiences. Goffman’s

(1959) proposal that individuals ‘perform roles’ laid a foundation on which

later theorists constructed theories about how one person may have many,

simultaneous identities which change both over time but in context. More

recently, identity theorists have focused on ways in which people

contribute to shaping their own identities (Woodward 2002), using

narrative as a tool to explore and explain who they, as individuals, are

(Lawlor 2008). Nevertheless, survey data presented here revealed that a

fairly large proportion of H&SC staff questioned felt that they had strong

ties to a ‘group’ identity – namely, that of their profession. 73.9% of

respondents suggested that they always or often felt that they ‘belonged’ to

their profession. For 16.4%, being a member of their H&SC profession

always defined who they feel they are. As the literature review identified

no ‘single professional identity’ which describes any one profession, these

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results serve as a reminder that there is no ‘single’ or unified experience of

any particular identity. However, as part of their individual identity, some

people do identify with certain groups, and in many instances this involves

their profession, or a sub-unit of their profession. More in-depth results

from the interviews confirmed that respondents expressed many different

narrative accounts of how and why they chose to become a member of a

certain profession, but for many, the ‘defining moment’ that confirmed

their professional identity involved an element or realisation of

responsibility towards both colleagues and patients / service users. This

relates to a concept developed in this thesis, that of ‘interprofessional

responsibility’, and indicates that for some H&SC professionals, such

responsibility is already part of their professional identities.

2. Socialisation is key to professional identity development in H&SC

Literature on professions also identified the significance of the process of

‘socialisation’ in the development of professional identity, including the

importance of mentors and learning environments (Lindquist et al. 2006;

Gray and Smith 1999). Results from the survey indicated that the majority

of NHS staff were involved in some way with students from H&SC

professions, even if this was only providing them with opportunities to

observe what they do. Unsurprisingly, respondents felt that they were

much more likely to work with student members of their own profession

than with those of other professions, and as for directly influencing

students from other professions (through assessment, for example), only

15.5% of respondents stated that they ever do so (and only 5.4% did so

‘often’). The theme of ‘socialisation’ also strongly emerged from the

interviews. Participants acknowledged the influence of their work-based

experiences in developing professional identities, and in particular, the

importance of having positive role models, and sometimes, conversely, the

impact of observing examples of behaviour in practice they did not wish to

emulate. This theme is revisited in the summary of findings exploring the

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relationship between collaborative practice and professional identity

(question 2).

3. The concept of ‘academic identity’ with specific relation to H&SC

staff is worthy of further study

The literature review did not identify work specifically concerned with

exploring the identity of H&SC academics, although the ‘teaching identity’

was sometimes discussed in other works (Lake 2004; Meerabeau 1998).

Both the survey data (albeit based on small numbers of respondents) and

interview responses indicated that academics were split in terms of views

on their professional identity, with some relating themselves to the role of

‘teacher’ and others more to the profession in which they qualified. Many

academics interviewed also indicated that teaching was not something they

had actively sought, rather that they had often started work in academia

because an opportunity had presented itself at a particular time. While it is

possible that this has no impact on the professional identity of staff,

‘academic identity’ may be an area worthy of further study, particularly for

those with an interest in socialisation processes.

4. Existing academic conceptualisations of ‘professional identity’ do

not align with the way in which H&SC professionals actually perceive

their own identity; conceptualising H&SC professionals as having an

intra-professional identity may therefore be more useful than using

whole-profession labels

A large body of work concerning the development of professional identities

of a number of different professions was discussed in Chapter Two.

Debates surrounding each professional identity could be linked to the

history of the profession; for example, where it has been identified that

nurses feel a lack of socio-professional recognition, it could be seen as

emerging from a long debate concerning whether an occupation involving

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‘caring’ should be defined as a profession. It has been proposed that rather

than thinking of professions along a continuum, where one profession is

viewed as more professional than another, it might be more useful to think

of each occupation as ‘differently professional’, so that strengths each

profession brings to a team can be valued equally. Again, this can be

conceptualised as aligning identity with an understanding of

interprofessional responsibility. Some interview respondents identified

instances where this already happens, describing working life as

impossible without interprofessional collaboration. Nevertheless, missed

opportunities for collaboration and the difficulties of passing on this

experience to students were acknowledged. However, where respondents

sometimes viewed some interprofessional responsibility as part of their

own identity, they were less likely to identify with a professional label such

as those described in Chapter Two, and more likely to define themselves by

their intra-professional identity or role. This was sometimes context

dependent (i.e. professionals taking on different roles in different teams)

and often related to the specialty or branch of a profession to which they

were aligned. However, this conceptualisation of identity is in notable

contrast to much of the literature which describes professions as a whole

(i.e. as ‘nursing’ rather than child nursing, adult nursing and learning

disability nursing, for example). One possible consequence is that academic

descriptions of professional identities are misaligned with the reality of

professionals’ interpretations of their own identity, which has implications

for the further study of both professional identity and IPE (see Section 7.2).

5. Perceived ‘strength’ of professional identity does not translate to

the core values of a profession

Participants’ perceptions of the strength of professional identity were

particularly interesting. While talking about their own professional

identities, a feeling of a strong identity was often aligned with being

passionate about one’s profession and the values of the profession being

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embedded in who they were as individuals. To an extent, this may be

related to the type of professional more likely to take part in such a study

as this, who are potentially more likely than others to be advocates for

their profession. There was also some discussion about a stronger sense of

professional identity aligning with senior status, again implying a

relationship between professional identity and responsibilities. However,

in talking about professions as a whole, respondents were much less likely

to claim that their own had a strong identity, and more likely to suggest

that other professions had a stronger identity. While there does appear to

be some support for the notion that a strong individual identity is linked to

core professional values, these core professional values do not appear to

translate into a strong identity for a profession as a whole. As noted in

Chapter Two, however, the mantra of ‘our profession does not have a

strong identity’ seems prevalent in literature about some professions,

particularly occupational therapy; it may therefore be the case that

students are socialised into stating that this is the case even when it may

not be true. It may also be true that a profession as a whole with a

perceived strong identity is seen in a more negative light, even though this

did not appear to be the case for respondents here; rather, they felt that

their own professions had weaker identities because their roles were not

always recognised and understood by other professions or the public.

6. Negative attitudes concerning other professions are sometimes

expressed despite acknowledgement that IPE is important

Finally, on perceptions of identities of other professions, there was an

element of ‘negative leakage’ in opinions expressed during interviews.

While respondents did not make direct negative comments concerning

another profession or their identity during interviews, a number of

comments expressing less than favourable opinions about other

professions ‘leaked out’ during the course of them. This occurred despite

the fact that all respondents expressed a positive attitude towards the

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concept of IPE and its aims. While this may not indicate a problem in itself,

it may be the case that such opinions are expressed in front of, or directly

to, students; for this reason, implications arise concerning socialisation and

the impact of such negative comments. Indeed, this finding may strengthen

the already strong case presented by work discussed in Chapter Three,

which identifies the need to support staff as IPE facilitators to ensure that

staff can sustain commitment to IPE, in terms of both time and attitude

(Curran et al. 2007; Freeman et al. 2010; Anderson et al. 2009; 2011).

Do practicing H&SC staff perceive that ‘professional identities’ are reinforced,

challenged or changed by IPE and / or collaborative practice?

As expected, respondents’ experiences of IPE varied greatly. From analysis

of the survey data, there was no evidence that experiences of IPE resulted

in differing attitudes towards professional identities or collaborative

practice, although this is a very ‘blunt instrument’ for exploring a complex

interaction where the impact of IPE was never likely to be separated from

respondents’ other experiences. It was always unlikely that a relationship

between these variables would be apparent in the survey data.

7. Attitudes of H&SC staff towards the concept of IPE are generally

positive, regardless of personal experiences

The interviews explored this topic in a more nuanced way. Many

respondents felt that IPE should change professional identities in a positive

manner – that is, by enabling people who receive IPE to have a better

understanding of their roles and a clearer notion of their responsibilities

for collaborative working. (This was in contrast to survey respondents

who were asked, based on their own experiences, to rate how successful

they felt IPE could be in achieving certain aims. Their responses suggested

that IPE was most successful in improving team-working and patient care,

but less likely to be successful in helping students understand their own

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limitations.) Yet opinions expressed in the interviews were seemingly not

based on experiences of IPE. Indeed, those respondents who reported

having negative experiences of IPE still suggested that attitudes towards

collaborative practice could be positively changed by IPE. Thus, such

opinions were not based on experience but rather expressed as a hope for

what IPE might achieve. In Chapter Three it was argued that part of the

way in which IPE has been viewed as ‘the answer’ to issues in H&SC has

been because of the dominant policy discourse it has occupied in both

politics and for the regulatory bodies; this might help to explain why,

despite negative personal experiences of IPE for some staff, and admissions

by others that what they delivered was about ‘ticking boxes’ rather than

quality provision of interprofessional experiences, IPE was generally

discussed by participants in a positive light.

8. Both professional identity and the ability to work collaboratively

appear to strengthen with experience rather than through being

taught

It should also be noted that some respondents felt that IPE could not

change professional identities, due both to socialisation processes and to

the fact that, once in practice, people become entrenched in their own

professions. This fits in with literature discussed in Chapter Two, which

suggested that socialisation processes lead to ‘tribalistic’ behaviours

(Beattie 1995; Hall 2005). However (despite some negative comments

about other professions, as discussed previously), there was no evidence of

particularly ‘tribalistic’ behaviours or ‘silo working’ in either survey or

interview responses. What the survey results did imply was that junior

staff were more likely to agree that they found it easier to communicate

and to work with members of their own profession. One interpretation of

this finding is that being able to collaborate effectively across different

professions develops with experience, and as such is a difficult skill to

‘teach’. Nevertheless, this could also be related to the suggestion made

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earlier that professional identity becomes stronger with experience, and

that as individual develop a stronger professional identities – or a sense of

a professional identity – they are better able to work with other

professions. This is not to suggest that one of these occurrences (a

stronger professional identity or ability to work collaboratively) causes

another, but that as both can be seen to develop with experience, it appears

that a stronger professional identity is related to the ability to collaborate

across professional boundaries.

9. Role-models of both ‘good’ and ‘bad’ professional behaviours are

identifiable in practice experiences

As highlighted in the discussion concerning perceptions of professional

identity, many interview respondents in this study cited the importance of

good role models in developing both their own professional identity and

collaborative practice. Some respondents also identified that where they

had seen examples of ‘bad’ practice, giving them an understanding about

how not to behave. This is slightly at odds with Pollard’s (2008)

observation that students may learn ‘inappropriate behaviours’ from

examples of poor collaborative working. While this may of course be true,

it may also be the case that some students are mature enough to recognise

poor behaviours, as appears to have been the case for interviewees in this

study. Nevertheless, whether through witnessing poor, exemplary or any

other type of behaviour, the pivotal role of practice-based experiences in

forming both professional identity and opinions towards IPE and

collaborative practice has been acknowledged in existing literature (Dando

et al. 2011; Wilhelmsson et al. 2009; Wahlström and Sandén 1998;) and in

the findings of this study.

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10. The concept of ‘professional alliances’ may be useful to educators

when planning the development of IPE

In exploring the way in which professional identity may be perceived as

being influenced by IPE and collaborative practice, this research has

several times discussed the concept of ‘professional alliances’. The concept

emerged when respondents were asked to identify if there were some

professions they found it easier than others to work with. Responses either

concerned the fact that ease of working with others was due to individual

personalities, or because certain professions were more ‘naturally’ aligned

with their own. Occupational therapists, for example, spoke of how they

worked closely with physiotherapists; speech and language therapists

talked of working with dieticians. Respondents reflected that this ‘ease’ of

working with particular other professions was because staff came from a

similar evidence-base or worked towards the same patient-focused goal/s.

The notion of ‘professional alliances’ can also be perceived in the notion

that IPE initiatives need to be made relevant to students for them to be

most effective; this was again a suggestion made by respondents when

asked about the most appropriate time to introduce IPE, but also identified

in IPE literature (Rosenfeld et al. 2011; Anderson and Thorpe 2008). The

notion of professional alliances can also be seen in the previously discussed

concept of intra-professional identity. Where interview respondents

identified themselves by their specialty or branch, this was often

accompanied by reflection that they were more closely aligned to branches

of other professions than with different branches of their own; for example,

a child social worker aligned his working practices with child nurses rather

than with adult social workers. The concept of professional alliances may

therefore be useful for educators to consider when aiming to develop

effective, relevant IPE that changes professional identity in a positive way

(through the introduction of the concept of interprofessional

responsibilities, for example).

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11. IPE appears to be more about ‘ticking boxes’ for some academic

institutions, rather than about improving collaboration and standards

of patient care

Finally it should be noted that although some respondents were able to talk

about positive experiences of IPE, others – in particular academic

respondents – reported that in some cases, IPE had very much become a

‘tick-box’ exercise, which was done to show it was being done, rather than

as a meaningful experience for students. A question therefore remains

about the extent to which IPE has become a ‘mantra’ for educators, one

driven by policy changes and regulatory body requirements (discussed in

Chapter Three), and which has since lost its purpose and meaning. The

importance for educators of returning to the underlying ethos of IPE,

educating H&SC students to learn with and from and about one another to

improve collaboration and the standards of patient care, remains as

important today as it ever has been.

What impact does the implementation of a large-scale interprofessional

programme have on staff involved in delivering the programme?

Chapter Five outlined the activities of the ALPS CETL, which was chosen as

a case study for this research due to its unusually large size as an

interprofessional programme of work. Incorporating five West Yorkshire

Universities and sixteen H&SC professions, the ALPS CETL aimed amongst

other things to introduce an interprofessional element into work-based

assessments. As part of the development work for the CETL, staff involved

in the collaboration worked with colleagues from professions and

institutions with whom they had previously had no contact. This research

was interested in establishing what long term impact, if any, being involved

in such a large-scale interprofessional programme of work would have on

the staff involved. In addition to the contribution that this element of the

work made to the question previously summarised concerning whether

perceptions of professional identity are challenged, reinforced or changed

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by IPE, a number of findings specifically related to the experiences of those

involved in the ALPS CETL also emerged.

12. Staff perceived benefit from involvement in a large-scale IPE

programme through working with professions they would not

normally work with

Responses given by interview participants indicate that involvement in

ALPS resulted in some positive personal experiences and results, but not

necessarily ones expected or aimed for at the beginning of the programme.

Due to the multi-faceted nature of ALPS, it initially appeared difficult to

separate out the impact of interprofessional working from other elements

of the programme, but after closer interrogation of data, it emerged that

staff working in all aspects of the programme had benefitted from its

interprofessional nature, often involving exposure to working with

partners they would not otherwise have worked with.

13. ‘Barriers’ to IPE are often perceived rather than evidenced

Both this research and ALPS documents / research reports highlight that

engaging in interprofessional working involved certain challenges.

However, as noted in the literature review, it is also apparent that these

challenges are typical of all interprofessional programmes, regardless of

their size. To some extent, these challenges are not about ‘inter-

professional’ strands of work, but rather concern perceived barriers in the

form of regulatory bodies and practical elements (Baines et al. 2010), as

well as physical locations, opportunities, time, and space in which to meet

people from outside one’s own profession in an academic environments

(Solomon et al. 2010; Begley 2009; Mayers et al. 2006). However, staff

from the ALPS programme still perceived barriers for effective IPE which

related to protectiveness over professional identity formation among

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students (although for the most part, no recognition was given to the

impact that staff may have on this through socialisation processes).

14. ‘Unusual’ interprofessional collaborations in education may result

in learning, but may not be sustainable working partnerships

The case study has also raised a question about whether large scale IPE is

sustainable. Clearly this will depend upon the definition of ‘large-scale’, but

it is noticeable that the majority of large-scale (cross-institution, five+

professions) funded programmes of IPE are either scaled-back or

disappear completely once funding ends. The difference with funded

programmes of work, and those perhaps that develop more ‘organically’, is

that funded programmes often bring professions together who may not

have considered working together previously (and are possibly funded

specifically for this reason). However, once funding has ended, those

professions may not have identified further reasons to work together if IPE

has not been made relevant to their profession. For example, one

profession involved in ALPS was dentistry, which was not represented in

this study but also not mentioned by any participant in the research. The

reason is probably its lack of relevance to any other working practice; it is

unlikely that the majority of other ALPS professions will come across, or

need to work with, dentists in their professional lives. Indeed, for dentists

themselves, the most relevant ‘interprofessional’ collaborations will be

with other dental professions (dental hygienists or dental nurses, for

instance). It might therefore be proposed that large-scale programmes

based on ‘unusual’ collaborations do not need to be sustained; once ‘doors

have been opened’ and the programme of work has been achieved, it might

be questioned what further, similar collaborations can achieve. In the case

of ALPS, it appears that the most important outcome for most professionals

was the impact of learning during the programme and projects that

emerged as a result.

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With only 2 – 3 years between the end of the main ALPS programme and

the majority of this research being conducted, it is too soon to judge

whether this will be the most enduring ‘legacy’ of the ALPS programme; as

ever with curriculum initiatives, it becomes problematic to separate out the

impact of one project from developments that might have occurred

anyway. At the time ALPS participants were interviewed, however, the

development of more relevant IPE initiatives improved on the basis of

lessons learned from ALPS were the most important result, and, as

discussed in Chapter Three, some literature suggests that it is such

‘relevant’ programmes that are more likely to be sustained, as well as

having more meaningful impact for participants (Miller et al. 2006;

Anderson and Thorpe 2008).

7.3 Implications and recommendations

The final research question posed at the start of this thesis was:

What implications do conceptualisations of professional identities and IPE

have for the implementation of educational initiatives aimed at improving

teamwork between professions for the ultimate aim of improving service user

care?

The following section considers these implications, and makes

recommendations for educators and others based on the findings from this

research.

1. ALL H&SC professionals need to recognise their responsibilities

towards collaborative practice as part of their identity

The research identified that for some H&SC professionals, responsibilities

towards working with other professionals were seen as defining elements

of professional identity. However this was not the case for all respondents.

Where there is a recognition that collaborative practice needs to occur for

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all H&SC systems to work, the implication is that all H&SC professionals

need to recognise this responsibility as part of their identity, and that

education and training initiatives must focus on developing it in H&SC

students early in their training.

2. All H&SC staff need to be mindful of opinions they express

regarding all professions, particularly in front of students

While identity has been recognised in this thesis as unique for each

individual, it has also been possible to see that the socialisation processes

in H&SC are remarkably influential in the formation of identity. All H&SC

staff, both practicing and academic, need to be mindful of this and the

impact that they have on future generations of professionals. This includes

the importance of having personal ‘interprofessional responsibility’ when

expressing opinions concerning IPE, collaborative practice or other

professions.

3. IPE should be delivered across or between professional boundaries

that are seen as most relevant to practice experiences

The way in which some staff conceptualise their identity in an intra-

professional way (rather than aligning their identity to a professional label)

also has implications for the design of IPE. This was related to the notion of

‘professional alliances’ – that is, that some professions found it easier to

work together because of a closely shared ethos or client base.

Conceptualisations of IPE have typically (but not always) concerned

working across professional boundaries, yet it may be true that, if relevant,

IPE should also relate to working between branches of professions.

Alternatively, ensuring that IPE incorporates those professions most

closely aligned may be another way to ensure IPE is as relevant as possible

for students. However, this should not be done to the detriment of

relationships with other H&SC professions, and caution may be required to

258

ensure different ‘tribes’ do not emerge out of ‘allied’ professions. The

notion of intra-professional identities is also important for the study of

identity in H&SC more generally, as it appears to be relatively unrecognised

in literature at the moment.

4. Further work on ‘academic identity’ in H&SC is required

A further area of work on identity that appears relatively under-studied is

that of the academic identity of those who teach H&SC professions. This

research identified that academics who work in this field often do so

because they happen to have been ‘in the right place at the right time’, but

are relatively ambivalent about their identities. It is not possible to state

from research conducted here whether this has implications for either staff

or students, but, as it is possible that this may influence the way students

form their own identities and think about their future teaching roles (all

H&SC roles involve some element of teaching), this is also a worthy area of

further study.

5. Educators need to prepare students for collaborative working, but

should recognise that alongside professional identity, the ability to do

this effectively is something that develops with experience

There was some recognition from participants in this study that some

things cannot be taught, such as those things learnt from experience, which

include particular collaborative working practices and (for some) a

stronger sense of professional identity that develops over time. Instead of

trying to teach these things, educators need to focus on preparing students

to understand that they will develop over time. Simultaneously, it should

be recognised that the mantra of ‘our profession has a weak identity’ can

become a self-fulfilling prophecy as students become socialised into this

way of thinking.

259

7.31 Further implications and going forward

In addition to the outlined implications of this research that have arisen out

of perceptions of professional identities and IPE, some further implications

specifically concerning the provision of IPE are also evident in the findings.

These implications are noted here, alongside some suggestions for

additional lines of inquiry for those interested in improving best practice in

this area and further recommendations for those implementing IPE.

6. Further research is needed in order to understand if undertaking

IPE with one professional group impacts on changes in ability to

undertake collaborative practice with all professions

The literature review identified that there was some increasing evidence

that if IPE was carried out in relevant and timely ways in a practice

environment, then this often has a positive impact on attitudes towards,

and understandings of, collaborative practice. However, given the

practicalities of organising and running IPE in this way, combined with the

issue of uneven student numbers from different professions, this is not

always a feasible model. What is not clear from the literature is whether

undertaking IPE with one other professional group would have a beneficial

impact upon attitudes towards, or ability to undertake, collaborative

practice with any other, or indeed all, professions. This may be an

interesting avenue of further research that may help to address the

practical and organisational issues surrounding the delivery of IPE which

many institutions face.

7. Educators should seek to move away from IPE as a box-ticking

exercise, and seek out examples of good collaborative practice and

placement learning opportunities

The research found that staff are able to identify that many opportunities

for IPE and collaborative practice are missed, particularly with reference to

260

learning from placement experiences. In conjunction with the finding that

some IPE provided by HEIs is viewed as little more than ‘box-ticking’ by

staff providing it, there is a responsibility for educators to move away from

this type of provision and to seek examples of good collaborative practice

already occurring, enabling students to make the most of their placement

learning opportunities.

8. Students need to be taught to recognise poor collaborative

behaviours

Where positive role models have always been recognised as influential, this

research has found that poor behaviour can also influence students to react

in a positive way, giving them an example of behaviours they do not wish to

exhibit themselves. However, the implications are that students need to be

able to recognise poor collaborative behaviours, and that when they do

witness them, they also need to recognise that they can learn from these

examples without needing to mimic them. This reinforces the suggestion

that it is important to introduce the concepts of IPE and collaborative

practice early in H&SC professional training, and that incorporating

‘interprofessional responsibility’ into all H&SC identities may assist with

this.

9. IPE needs to be relevant to all participants

While already identified in existing literature, the findings of this research

have reinforced the importance of the need for IPE to be relevant to

participants. Not only should IPE not be about ‘box-ticking’ and getting it

completed, relevance needs to be made clear to all those involved;

otherwise, as with participants in this study, they will identify that the IPE

served more of a purpose for the institutions delivering it than for them as

students.

261

10. Educational institutions have a responsibility to ensure

professions of all sizes are able to join or learn from IPE initiatives

The case study research also raised a question concerning whether larger

professions have responsibilities to involve smaller professions in IPE

programmes, ensuring best practice is shared. While this is perhaps the

case, it would undermine arguments made here if this was done to the

detriment of the initiative’s relevance. In this instance, it may be the

responsibility of the wider academic institution to ensure that professions

of all sizes can share best practice around IPE initiatives, and that, where

possible and relevant, smaller professions are invited to take part or

encouraged to develop their own IPE. However, it should also be pointed

out that learning outcomes from an IPE initiative do not need to be the

same for all professions involved. As long as each professions’ learning

outcomes from IPE are relevant, there is nothing to suggest that

professions cannot be brought together to learn something different from

same experiences.

11. All professions need to understand their interprofessional

responsibilities in order to ensure the best possible patient care

Finally, at certain points in this thesis it has been suggested that as

collaborative practice ‘happens anyway’, and has to some extent always

happened, ‘IPE’ might be considered a false construct which was created

and is understood by academics, but is less clear in practice. While this

may be true, the fact that failures of patient care in the H&SC system are

still attributed to an inability of H&SC professionals to communicate or

work effectively together implies a need for continued focus on improving

this element of H&SC work. Whether all H&SC staff precisely understand

the definition of IPE and its aims is less important than the need for them to

understand responsibilities towards working together effectively,

providing the best possible care to all patients and service users.

262

Bibliography

Abbott, A. 1988. The System of Professions. An Essay on the Division of

Expert Labor. Chicago: The University of Chicago Press.

Abbott, P. and Meerabeau, L. 1998. Professionalization and the Caring

Professions. In: Abbott, P. and Meerabeau, L. (eds) The Sociology of the

Caring Professions. Second Edition. Abingdon: Routledge, pp.1-19.

Abbott, P. and Wallace, C. 1998. Health Visiting, Social Work, Nursing and

Midwifery. In: Abbott, P. and Meerabeau, L. (eds) The Sociology of the

Caring Professions. Second Edition. Abingdon: Routledge, pp.20-53.

Aberdeen Interprofessional Health and Social Care Education. 2014.

AIHSCE Website. [Online]. [Accessed 15 March 2014]. Available from:

http://www.ipe.org.uk

Adams, K., Hean, S., Sturgus, P. and Macleod Clark, J. 2006. Investigating the

factors influencing professional identity of first-year health and social care

students. Learning in Health and Social Care. 5(2), pp.55-68.

Alexander, V.D., Thomas, H., Cronin, A., Fielding, J. and Moran-Elis, J. 2008.

Mixed Methods. In: Gilbert, N. (ed) Researching Social Life. Third Edition.

London: Sage, pp.125-44.

ALPS. 2004. Invitation to bid for funds (recurrent and capital) to establish

Centres for Excellence in Teaching and Learning from 2004–2005.

Unpublished.

ALPS. 2007. Assessment and Learning in Practice Settings (ALPS) A Centre

for Excellence in Teaching and Learning. Interim Evaluation Report.

[Online]. [Accessed 24 February 14]. Available from: http://www.alps-

cetl.ac.uk/interimreport/ALPSInterimEvaluationReportJuly2007v2.pdf

ALPS. 2010. ALPS summative evaluation – part 2 evaluative reflection.

[Online]. [Accessed 04 March 14]. Available from: http://www.alps-

cetl.ac.uk/documents/ALPSsummativeevaluation.pdf

263

ALPS and The ROI Academy. 2010. Cost Benefit Analysis of the ALPS

Programme. Briefing. [Online]. [Accessed 15 July 2014]. Available from:

http://www.alps-cetl.ac.uk/documents/ROIbriefFINAL.pdf

ALPS. ALPS Website. [Online]. [Accessed 14 March 2014]. www.alps-

cetl.ac.uk

Anderson, E.S., and Thorpe, L.N. 2008. Early interprofessional interactions:

Does student age matter? Journal of Interprofessional Care. 22(2), pp.263-

282.

Anderson, E.S., Cox, D. and Thorpe, L.N. 2009. Preparation of educators

involved in interprofessional education. Journal of Interprofessional Care.

23(1), pp.81-94.

Anderson, E.S., Smith, R. and Thorpe, L.N. 2010. Learning from lives

together: medical and social work students’ experiences of learning from

people with disabilities in the community. Health and Social Care in the

Community. 18(3), pp.229-240.

Anderson, E.S., Thorpe, L.N., and Hammick, M. 2011. Interprofessional staff

development: Changing attitudes and winning hearts and minds. Journal of

Interprofessional Care. 25(1), pp.11-17.

Apker, J. and Eggly, S. 2004. Communicating Professional Identity in

Medical Socialization: Considering the Ideological Discourse of Morning

Report. Qualitative Health Research. 14(3), pp.411-429.

Archer, L. 2008. Younger academics’ constructions of ‘authenticity’,

‘success’ and professional identity. Studies in Higher Education. 33(4),

pp.385-403.

Ashforth, B.E. and Mael, F. 2004. Social Identity Theory and the

Organization. In: Hatch, M.J. and Schultz, M. (eds) Organizational Identity.

A Reader. Oxford: Oxford University Press, pp.134-160.

Atkins, J. 1998. Tribalism, loss and grief: issues for multiprofessional

education. Journal of Interprofessional Care. 12(3), pp.303-307.

264

Atkinson, P. 1983. The Reproduction of the Professional Community. In:

Dingwall, R., and Lewis, P. (eds) The Sociology of the Professions: Lawyers,

Doctors and Others. Basingstoke: The Macmillan Press Ltd, pp.224-241.

Baines, S., Wilson, R. and Walsh, S. 2010. Seeing the full picture?

Technologically enabled multi-agency working in health and social care.

New Technology, Work and Employment. 25(1), pp.19-33.

Baldwin, T.T. and Ford, J.K. 1988. Transfer of training: A review and

directions for future research. Personnel Psychology. 41, pp.63-105.

Baker, L., Egan-Lee, E., Martimianakis, M.A. and Reeves, S. 2011.

Relationships of power: implications for interprofessional education.

Journal of Interprofessional Care. 25(2), pp.98–104.

Barr, H., Hammick, M., Koppel, I., and Reeves, S. 1999. Evaluating IPE: two

systematic reviews for health and social care. British Education Research

Journal. 25(4), pp.533–544.

Barr, H., Koppell, I., Reeves, S., Hammick, M. and Freeth, D. 2005. Effective

Interprofessional Education. Argument, Assumption, Evidence. Oxford:

Blackwell.

Barr, H. (ed) 2007. Piloting Interprofessional Education. Four English Case

Studies. Occasional Paper No. 8. London: Higher Education Academy Health

Sciences and Practice Subject Centre.

Barr, H., Helme, M. and D’Avray, L. 2011. Developing Interprofessional

Education in health and social care courses in the United Kingdom. A

Progress Report. Occasional Paper 12. London: Higher Education Academy

Health Sciences and Practice Subject Centre.

Barr, H., and Sharland, E. 2012. Interprofessional Education in Qualifying

Social Work. In: Lishman, J. (ed) Research Highlights in Social Work 54.

Social Work Education and Training. London: Jessica Kingsley Publishers,

pp.119-213.

Bauman, Z. 2004. Identity. Cambridge: Polity Press.

265

Baxter, S.K. and Brumfitt, S.M. 2008. Professional differences in

interprofessional working. Journal of Interprofessional Care. 22(3), pp.239-

251.

Beagan, B.L. 2001. “Even if I don’t know what I’m doing I can make it look

like I know what I’m doing”: Becoming a doctor in the 1990s. Canadian

Review of Sociology. 38(3), pp.275–292.

Beattie, A. 1995. War and peace among the health tribes. In: Soothill, K.,

Mackay, L. & Webb, C. (eds) Interprofessional relations in health care.

London: Edward Arnold, pp.11-26.

Becher, T. and Trowler, P. 2001. Academic tribes and Territories. Second

Edition. Buckingham: Open University Press.

Becker, H.S., Geer, B., Hughes, E.C. and Strauss, A.L. 1961. Boys in White.

Student Culture in Medical School. Chicago: University of Chicago Press.

Becker, H.S. 1971. Sociological Work. Chicago: Aldine.

Beck, J. and Young, M.F.D. 2005. The assault on the professions and the

restructuring of academic and professional identities: a Bernsteinian

analysis. British Journal of Sociology of Education. 26(2), pp.183-197.

Beech, N. and Sims, D. 2007. Narrative methods for identity research. In:

Pullen, A., Beech, N. and Sims, D. (eds) Exploring Identity. Concepts and

Methods. Basingstoke: Palgrave Macmillan, pp.288-301.

Begley, C.M. 2009. Developing inter-professional learning: tactics,

teamwork and talk. Nurse Education Today. 29(3), pp.276-283.

Berg, B.W., Wong, L. and Vincent, D.S. 2010. Technology-enabled

interprofessional education for nursing and medical students: a pilot study.

Journal of Interprofessional Care. 24(5), pp.601–604.

Best, S.J. and Krueger, B.S. 2008. Internet Survey Design. In: Fielding, N.,

Lee, R.M. and Blank, G. (eds) The Sage Handbook of Online Research

Methods. London: Sage, pp.217–235.

266

Blaikie, N. 2000. Designing Social Research. Cambridge: Polity Press.

Blom-Cooper QC, L. 1990. Occupational Therapy. An emerging profession in

healthcare. Report of a Commission of Inquiry. London: Gerald Duckworth

& Co.

Blumenfeld, P., Marx, R., Patrick, H., Krajcik, J. and Soloway, E. 1997.

Teaching for understanding. In: Biddle, B.J., Good, T.L. and Goodson, I.F.

(eds) International handbook of teachers and teaching. Dordecht: Kluwer,

pp.819-878.

Bogner, A. and Menz, W. 2009. The Theory-Generating Expert Interview:

Epistemological Interest, Forms of Knowledge, Interaction. In: Bogner, A.,

Littig, B. and Menz, W. Interviewing Experts. Research Methods Series.

Basingstoke: Palgrave Macmillan, pp.43–80.

Bolderston, A., Lewis, D. and Chai, M.J. 2010. The concept of caring:

Perceptions of radiation therapists. Radiography. 16(3), pp.198–208.

Bolton, S.C. 2000. Who cares? Offering emotion work as a “gift” in the

nursing labour process. Journal of Advanced Nursing. 32(3), pp.580–586.

Booth, J. and Hewitson, A. 2002. Role overlap between occupational

therapy and physiotherapy during in-patient stroke rehabilitation: an

exploratory study. Journal of Interprofessional Care. 16(1), pp.31–40.

Bradburn, N.M., Seymour Sudman, E.B. and Associates. 1979. Improving

Method and Questionnaire Design. San Francisco: Jossey-Bass.

Brannen, J. 1992. Combining qualitative and quantitative approaches: an

overview. In Brannen, J. (ed) Mixing Methods: qualitative and quantitative

research. Aldershot: Ashgate Publishing Limited, pp.3-38.

Brante, T. 1988. Sociological Approaches to the Professions. Acta

Sociologica, 31(2), pp.119-142.

Braun, V. and Clarke, V. 2006. Using thematic analysis in psychology.

Qualitative research in psychology. 3(2), pp.77–101.

267

Breakwell, G.M. 1986. Coping with Threatened Identity. London: Methuen.

Brewer, M.B. 1979. In-group bias in the minimal intergroup situation: A

cognitive-motivational analysis. Psychological Bulletin 86(2), pp.307–324.

Brown, G.T. and Greenwood, J. 1999. Occupational therapy and

physiotherapy: similar but separate. British Journal of Occupational

Therapy. 62(4), pp.163–170.

Brown, R., Condor, S., Mathews, A., Wade, G., and Williams, J. 1986.

Exploring intergroup differentiation in an industrial organization. Journal

of Occupational Psychology. 59(4), pp.273-286.

Brown, J.S., Collins, A. and Duguid, P. 1989. Situated cognition and the

culture of learning. Educational Researcher. 18(1), pp.32-42.

Bryman, A. 1988. Quantity and Quality in Social Research. London:

Routledge.

Bryman, A. 1992. Quantitative and qualitative research: further reflections

on their integration. In Brannen, J. (ed) Mixing Methods: qualitative and

quantitative research. Aldershot: Ashgate Publishing Limited, pp.57-78.

Bryman, A. 2012. Social Research Methods. Fourth Edition. Oxford: Oxford

University Press.

Bulmer, M. 2008. The Ethics of Social Research. In: Gilbert, N. (ed) (2008)

Researching Social Life. Third Edition. London: Sage.

Burrage, M. and Torstendahl, R. 1990. Professions in Theory and History.

London: Sage.

Calhoun, C. 1994. Social Theory and the Politics of Identity. In: Calhoun, C.

(ed) Social Theory and the Politics of Identity. Oxford: Blackwell, pp.9–36.

Cameron, A. 2011. Impermeable boundaries? Developments in

professional and inter-professional practice. Journal for Interprofessional

Care. 25(1), pp.53–58.

268

Campbell, M.J. and Swinscow, T.D.V. 2009. Statistics at Square One. 11th

edition. Oxford: Wiley-Blackwell.

Carbonaro, M., King, S., Taylor, E., Satzinger, F., Snart, F. and Drummond, J.

2008. Integration of e-learning technologies in an interprofessional health

science course. Medical Teacher. 30(1), pp.25–33.

Carlisle, C., Cooper, H. and Watkins, C. 2004. ”Do none of you talk to each

other?”: the challenges facing the implementation of interprofessional

education. Medical Teacher. 26(6), pp.545-552.

Carpenter, J. 2011. Evaluating Social Work Education: A Review of

Outcomes, Measures, Research Designs and Practicalities. Social Work

Education. 30(2), pp.122-140.

Centre for the Advancement of Interprofessional Education. (2013) CAIPE

Website. [Online]. [Accessed 24 March 2013]. Available from:

http://www.caipe.org.uk/resources/defining-ipe/

Chan, E.A. and Schwind, J.K. 2006. Two nurse teachers reflect on acquiring

their nursing identity. Reflective Practice. 7(3), pp.303–314.

Cheetham, G. and Chivers, G. 2005. Professions, Competence and Informal

Learning. Cheltenham: Edward Elgar.

Clapton, G., Cree.,V.E. and Smith, M. 2013. Moral panics and social work:

Towards a sceptical view of UK child protection. Critical Social Policy.

33(2), pp.197–217.

Clouder, D.L., Goodman, S., Bluteau, P., Jackson, A., Davies, B. and Merriman,

L. 2011. An investigation of “agreement” in the context of interprofessional

discussion online: A “netiquette” of interprofessional learning? Journal of

Interprofessional Care. 25(2), pp.112-118.

Clouston, T.J. and Whitcombe, S.W. 2008. The Professionalisation of

Occupational Therapy: a Continuing Challenge. British Journal of

Occupational Therapy. 71(8), pp.314–320.

269

Cohen, H.A. 1981. The Nurse’s Quest for a Professional Identity. California:

Addison-Wesley.

Cohen, S. 1972. Folk devils and moral panic: The creation of the Mods and

Rockers. London: MacGibbon and Kee.

Collier, P. 2001. A differentiated model of role identity acquisition.

Symbolic Interaction. 24(2), pp.217-235.

Common Learning Project (2014) Common Learning website. [Online]

[Accessed 14 March 2014]. Available from:

https://www.commonlearning.net/project/index.asp

Coombs, R.H. 1978. Mastering Medicine. New York: Free Press.

Cooper, H., Carlisle, C., Gibbs, T. and Watkins, C. 2001. Developing an

evidence base for interdisciplinary learning: a systematic review. Journal of

Advanced Nursing. 35(2), pp.228–237.

Cooper, H., Braye, S. and Geyer, R. 2004. Complexity and interprofessional

education. Learning in Health and Social Care. 3(4), pp.179–189.

Cooper, H., Spencer-Dawe, E. and McLean, E. 2005. Beginning the process of

teamwork: Design, implementation and evaluation of an inter-professional

education intervention for first year undergraduate students. Journal of

Interprofessional Care. 19(5), pp.492-508.

Craddock, D., O’Halloran, C., Borthwick, A. and McPherson, K. 2006.

Interprofessional education in health and social care: fashion or informed

practice? Learning in Health and Social Care. 5(4), pp.220–242.

Craddock, D., O’Halloran, C., McPherson, K., Hean, S. and Hammick, M. 2013.

A top-down approach impedes the use of theory? Interprofessional

educational leaders’ approaches to curriculum development and the use of

learning theory. Journal of Interprofessional Care. 27(1), pp.65–72.

Curran, V.R. and Sharpe, D. 2007. A Framework for Integrating

Interprofessional Education Curriculum for Health Sciences. Education for

270

Health. 20(3). [Online]. [Accessed 21 June 2013]. Available from

http://www.educationforhealth.net/

Curran, V.R., Sharpe, D., and Forristall, J. 2007. Attitudes of health sciences

faculty members towards interprofessional teamwork and education.

Medical Education. 41, pp.892–896.

Curran, V.R., Sharpe, D., Flynn, K. and Button, P. 2010. A longitudinal study

of the effect of an interprofessional education curriculum on student

satisfaction and attitudes towards interprofessional teamwork and

education. Journal of Interprofessional Care. 24(1), pp.41–52.

Currie, G. and Suhomlinova, O. 2006. The impact of institutional forces

upon knowledge sharing in the UK NHS: The triumph of professional power

and the inconsistency of policy. Public Administration. 84(1), pp.1–30.

Dalley, G. 1989. Professional ideology or organisational tribalism? The

health service–social work divide. In: Taylor, R. and Ford, J. (eds) Social

Work and Health Care. London: Jessica Kingsley, pp.102–117.

Dalley-Hewer, J., Clouder, D.L., Jackson, A., Goodman, S., Bluteau, P. and

Davies, B. 2012. Facilitating critical discourse through “meaningful

disagreement” online. Journal of Interprofessional Care. 26(6), pp.472–478.

Dando, N., d’Avray, L., Colman, J., Hoy, A. and Todd, J. 2011. Evaluation of an

interprofessional practice placement in a UK in-patient palliative care unit.

Palliative Medicine. 26(2), pp.178–184.

Davies, N., Joynes, V. and Walker, T. 2010. Assessment and Learning in

Practice Settings (ALPS) – Implementing a large scale mobile learning

programme. A report. [Online] [Accessed 24 January 2014]. Available

from: http://www.alps-cetl.ac.uk/documents/ALPS%20IT%20Report.pdf

Dearnley, C.A., Taylor, J.D., Laxton, J.C., Rinomhota, S. and Nkosana-

Nyawata, I. 2013. The student experience of piloting multi-modal feedback

tools in health and social care practice (work)-based settings. Assessment

and Evaluation in Higher Education. 38(4), pp.436-450.

271

D’Avray, L., Gill, E., and Coster, S. 2007. Case Study – Interprofessional

learning in practice in South East London. In: Occasional Paper No 8 -

Piloting Interprofessional Education: Four English Case Studies. London:

Higher Education Academy. [Online] [Accessed 15 March 2014] Available

from: http://www.health.heacademy.ac.uk/

D’Eon, M. 2005. A blueprint for interprofessional learning’ Journal of

Interprofessional Care. 19(Supplement 1), pp.49–59.

Department of Health. 1989. Caring for people: Community care in the next

decade and beyond. London: H.M.S.O.

Department of Health. 1990. The community care act. London: H.M.S.O.

Department of Health. 1998. Partnership in action, discussion document.

London: H.M.S.O.

Department of Health. 2001. The Report of the Public Inquiry into children’s

heart surgery at the Bristol Royal Infirmary 1984-1995. Learning from

Bristol. London: HMSO. Crown Copyright. CM 5207(I).

Department of Health. 2011. Working Together, Learning Together: a

framework for lifelong learning. London: HMSO.

De Leeuw, E.D. 2005. To mix or not to mix data collection modes in surveys.

Journal of Official Statistics. 21(2), pp.233–255.

Denscombe, M. 2010. Ground Rules for Social Research. Guidelines for Good

Practice. Maidenhead: Open University Press.

Deppoliti, D. 2008. Exploring How New Registered Nurses Construct

Professional Identity in Hospital Settings. The Journal of Continuing

Education in Nursing. 39(6), pp.255–262.

Deutschlander, S., Suter, E. and Lait, J. 2012. Models in interprofessional

education: the IP enhancement approach as effective alternative. Work

41(3), pp.253–260.

272

DeVillis, R.F. 2003. Scale development: Theory and applications. California:

Sage.

Dingwall, R. 1983. Introduction. In: Dingwall, R. and Lewis, P. (eds) The

Sociology of the Professions: Lawyers, Doctors and Others. Basingstoke: The

Macmillan Press, pp.1–13.

Dingwall, R., Rafferty, A.M. and Webster, C. 1988. An Introduction to the

Social History of Nursing. London: Routledge.

Donmoyer, R. 2000. Generalizability and the Single-Case Study. In: Gomm,

R., Hammersley, M. and Foster, P. (eds) Case Study Method. London: Sage.

Donnan, T., Al Ansari, A., Al Alawi, S. and Violato, C. 2014. The Reliability,

Validity and Feasibility of Multisource Feedback Physician Assessment: A

Systematic Review. Academic Medicine. 89(3), pp.511-516.

Douse, J., Derrett-Smith, E., Dheda, K. and Dilworth, J.P. 2004. Should

doctors wear white coats? Postgraduate Medical Journal. 80, pp.284–286.

Downe, S. 1990. A noble vocation. Nursing Times. 86(40), p24.

Dunning, J. 2010. GSCC to be scrapped. Community Care. [Online] [Accessed

10 May 2014]. Available from:

http://www.communitycare.co.uk/2010/07/26/gscc-to-be-scrapped/

Ekmekci, O. and Turley, C.L. 2008. Who wants (to be) a therapist:

promoting professional identity. Radiation Therapist. 17(1), pp.8–15.

Elston, S. and Holloway, I. 2001. The impact of recent primary care reforms

in the UK on interprofessional working in primary care centres. Journal of

Interprofessional Care. 15(1), pp.19–27.

Etzioni, A. 1969. The Semi-Professions and their Organisation. New York:

Free Press.

Eve, R. and Hodgkin, P. 2007. Professionalism and Medicine. In: Broadbent,

J., Dietrich, M. and Roberts, J. (eds) The end of the professions? London:

Routledge, pp.69–84.

273

Ewens, A. 2003. Changes in nursing identities: supporting a successful

transition. Journal of Nursing Management. 11(4), pp.224–228.

Fenwick, T. and Nerland, M. 2014. Sociomaterial professional knowing,

work arrangements and responsibility, New times, new concepts? In:

Fenwick, T. and Nerland, M. (eds) Reconceptualising Professional Learning.

Sociomaterial knowledges, practices and responsibilities. Abingdon:

Routledge, pp.1-7.

Finlay, L. 2002. ”Outing” the Researcher: The Provenance, Process, and

Practice of Reflexivity. Qualitative Health Research. 12(4), pp.531–545.

Foley, L. 2005. Midwives, marginality, and public identity work. Symbolic

Interaction. 28(2), pp.183-203.

Fontana, A. 2001. Postmodern Trends in Interviewing. In: Gobrium, J.F. and

Holstein, J.A. Handbook of Interview Research: Context and Method. London:

Sage, pp.161–176.

Fook, J., D’Avray, L., Norrie, C., Psoinos, M., Lamb, B. and Ross, F. 2013.

Taking the long view: Exploring the development of interprofessional

education. Journal of Interprofessional Care. 27(4), pp.286–291.

Foucault, M. 1988. Technologies of the self. Amherst: University of

Massachusetts Press.

Fowler Jr, F.J. 2009. Survey Research Methods. Fourth Edition. London:

Sage.

Fox, A. 1971. A Sociology of Work in Industry. London: Collier-Macmillan.

Francis, R. 2013. Report of the Mid Staffordshire NHS Foundation Trust

Public Inquiry. Executive Summary. London: The Stationery Office. Crown

Copyright. HC 947.

Freeman, S., Wright, A. and Lindqvist, S. 2010. Training for educators

involved in interprofessional learning. Journal of Interprofessional Care.

24(4), pp.375–385.

274

Freeth, D., Hammick, M., Koppel, I., Reeves, S. and Barr, H. 2002. A Critical

Review of Evaluations of Interprofessional Education. London: Learning and

Support Network, Centre for Health Sciences and Practice.

Freeth, D., Hammick, M., Reeves, S., Koppel, I. and Barr, H. 2005. Effective

interprofessional education: Development, delivery and evaluation. Oxford

Blackwell Publishing.

Freidson, E. 1983. The Theory of the Professions: State of the Art. In:

Dingwall, R. and Lewis, P. (eds) The Sociology of the Professions: Lawyers,

Doctors and Others. Basingstoke: The Macmillan Press, pp.19–37.

Freidson, E. 1986. Professional Powers. A Study of the Institutionalization of

Formal Knowledge. Chicago: The University of Chicago Press.

Freidson, E. 1994. Professionalism Reborn. Theory, Prophecy and Policy.

Cambrige: Polity Press.

Freshwater, D. 2000. Crosscurrents: against cultural narration in nursing.

Journal of Advanced Nursing. 32(2), pp.481–484.

Frost, H.D. and Regehr, G. 2012. “I AM a Doctor”: Negotiating the Discourses

of Standardization and Diversity in Professional Identity Construction.

Academic Medicine. 88(10), pp1570-1577.

Fuller, R., Coulby, C., Homer-Vanniasinkam, S., Hennessy, S. and Davies, N.

2009. e-Learning in medical education: Guide supplement 32.4 – Practical

application. Medical Teacher. 31(4), pp368–369.

Garfinkel, H. 1967. Studies in Ethnomethodology. London: Prentice-Hall,

Inc.

Gaskell, L. and Beaton, S. 2010. Inter-professional work based learning

within an MSc in Advanced Practice: Lessons from one UK higher education

programme. Nurse Education in Practice. 10(5), pp274–278.

Gee, J.P. 2005. An Introduction to discourse analysis: Theory and method.

Second edition. London: Routledge.

275

General Medical Council. 2003. Tomorrow’s Doctors. [Online]. [Accessed 24

March 20130. Available from:

http://www.gmc-uk.org/TomorrowsDoctors_2003.pdf_39262074.pdf

General Medical Council. 2008. Quality Assurance of Basic Medical

Education. Report on School of Medicine, University of Southampton.

[Online]. [Accessed 16 July 2014]. Available from: http://www.gmc-

uk.org/static/documents/content/Southampton.pdf

General Medical Council. 2009. Tomorrow’s Doctors. [Online]. [Accessed 24

March 2013]. Available from:

www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp

General Medical Council. 2013. GMC Website. [Online]. [Accessed 24 March

2013]. Available from: www.gmc-uk.org/

Gherardi, S. 2014. Professional knowing-in-practice: rethinking materiality

and border resources in telemedicine. In: Fenwick, T. and Nerland, M. (eds)

Reconceptualising Professional Learning. Sociomaterial knowledges,

practices and responsibilities. Abingdon: Routledge, pp.11-24.

Gibbs, G. 2007. Analyzing qualitative data. London: Sage.

Gibbs, V. 2013. The long and winding road to achieving professional

registration for sonographers. Radiography. 19(2), pp.164–167.

Gibelman, M. 1999. The Search for Identity: Defining Social Work – Past,

Present, Future. Social Work. 44(4), pp.298–310.

Giddens , A. 1990. The Consequences of Modernity. Cambridge: Polity Press.

Giddens, A. 1991. Modernity and Self-Identity. Self and Society in the Late

Modern Age. Stanford: Stanford University Press.

Gilbert, N. 2008. Research, Theory and method. In: Gilbert, N. (ed)

Researching Social Life. Third Edition. London: Sage, pp.21-40.

Gilham, B. 2008. Small-Scale Social Survey Methods. London: Continuum.

276

Goldie, J., Dowie, A., Cotton, P. and Morrison, J. 2007. Teaching

professionalism in the early years of a medical curriculum: a qualitative

study. Medical Education. 41(6), pp.610–617.

Greenwood, E. 1957. Attributes of a Profession. In: Zald, M. (ed) (1965)

Social Welfare Institutions. New York: Wiley, pp.509-523.

Goffman, E. 1959. The Presentation of Self in Everyday Life. London:

Penguin.

Goffman, E. 1962. Stigma. Notes on the Management of a Spoiled Identity.

New York: Simon and Schuster Inc.

Gordon, F., Walsh, C., Marshall, M., Wilson, F. and Hunt, T. 2004. Developing

interprofessional capability in students of health and social care – the role

of practice based learning. Journal of Integrated Care. 12(4), pp.12–18.

Gough, P. 2001. Changing culture and deprofessionalisation. Nursing

Management. 7(9), pp.8–9.

Gude, T., Vaglum, P., Tyssen, R., Ekeberg, O., Erlendm H., Rovik, J.O., Finset,

K. and Gronvold, N.T. 2005. Identification with the role of a doctor at the

end of medical school: a nationwide longitudinal study. Medical Education

39(1), pp.66-74.

Guiller, J. and Durndell, A. 2006. “I totally agree with you”: Gender

interactions in educational online discussion groups. Journal of Computer

Assisted Learning. 22(5), pp.368–381.

Haddara, W. and Lingard, L. 2013. Are we all on the same page? A

Discourse Analysis of Interprofessional Collaboration. Academic Medicine.

88(10), pp.1509-1515.

Hall, P. 2005. Interprofessional teamwork: Professional cultures as

barriers. Journal of Interprofessional Care. May 2005 Supplement 1,

pp.188–196.

277

Hallam, J. 2000. Nursing the image: Media, culture and professional identity.

London: Routledge.

Halmos, P. (ed) 1973. Professionalization and Social Change. Sociological

Review Monograph No 20. Keele: University of Keele.

Hammersley, M. 1992. Deconstructing the qualitative-quantitative divide.

In: Brannen, J. (ed) Mixing Methods: qualitative and quantitative research.

Aldershot: Ashgate Publishing Limited, pp39–55.

Hammersely, M. and Gomm. R. 1997. Bias in social research. Sociological

Research Online. 2(1), pp.1–17.

Hammick, M., Freeth, D., Koppel, I., Reeves, S. and Barr, H. 2007. A best

evidence systematic review of interprofessional education: BEME Guide no.

9. Medical Teacher. 29(8), pp.735–751.

Hammick, M., Olckers, L. and Campion-Smith, C. 2009. Learning in

interprofessional teams: AMEE Guide no 38. Medical Teacher. 31(1), pp.1-

12.

Hammond, G., Pearson, P., and Scott, L. 2010. CETL4HealthNE centre for

Excellence in Healthcare Professional Education. Final Self Evaluation for

HEFCE. Newcastle: CETL4HealthNE.

Hamstra, S.J., Woodrow, S.I. and Mangrulkar, R.S. 2007. Feeling pressure to

stay late: socialisation and professional identity formation in graduate

medical education. Medical Education 42(1), pp7-9.

Harden, R.M. 1998. Multiprofessional education: Part 1 - effective

multiprofessional education: a three-dimensional perspective. Medical

Teacher. 20(5), pp.402–408.

Harden, R.M., Grant, J., Buckley, G. and Hart, I.R. 1999. BEME Guide No. 1:

Best Evidence Medical Education. Medical Teacher. 21(6), pp.553-562.

278

Hargreaves, D.H. 1996. Educational research and evidence-based

educational practice – a response to critics. Research Intelligence. 58,

November, pp. 12–16.

Hargreaves, J., Nksana-Nyawata, I., Joynes, V., Millard, L. and Freeman, R.

(n.d.) Strength in Numbers? A collaborative approach to innovation in

professional education. [Online]. [Accessed 04 March 2014]. Available

from: http://www.alps-cetl.ac.uk/documents/Strengthinnumbers.pdf

Health Act 1999. (c.8). London: The Stationery Office.

Health and Social Care Act 2001. (c.15). London: The Stationery Office.

Health and Safety Executive. 2013. HSE Website. [Online]. [Accessed 14

June 2013]. Available from:

http://www.hse.gov.uk/healthservices/arrangements.htm

Hean, S., Macleod-Clarke, J., Adams, K., and Humphris, D. 2006a. Will

opposites attract? Similarities and differences in students’ perceptions of

the stereotype profiles of other health and social care professional groups.

Journal of Interprofessional Care. 20(2), pp.162–181.

Hean, S., Macleod-Clarke, J., Adams, K., Humphris, D. and Lathlean, K. 2006b.

Being seen by others as we see ourselves: the congruence between the

ingroup and outgroup perceptions of health and social care students.

Learning in Health and Social Care. 5(1), pp.10–22.

Hewstone, M. and Brown, R.J. (1986). Contact is not enough: an intergroup

perspective on the ‘contact hypothesis’. In: Hewstone, M. and Brown, R.J.

(eds) Contact and conflict in intergroup encounters. Oxford: Blackwell, pp.1-

44.

Higher Education Funding Council for England. 2014. HEFCE Website.

[Online]. [Accessed 08 January 2014]. Available from:

http://www.hefce.ac.uk/whatwedo/lt/enh/cetl/

279

Hilton, S.R. and Slotnick, H.B. 2005. Proto-professionalism: how

professsionalisation occurs across the continuum of medical education.

Medical Education. 39(1), pp.58–65.

Hochschild, A. 1979. Emotion work, feelng rules, and social structure.

American Journal of Sociology. 85(3), pp.551–575.

Hochschild, A. 1983. The Managed Heart: Commercialization of Human

Feeling. Berkeley: University of California Press.

Hogg, M.A. 2006. Social Identity Theory. In :Burke, P.J. (ed) Contemporary

Social Psychological Theories. Stanford: Stanford University Press, pp.111-

137.

Holstein, J.A. and Gubrium, J.F. 1995. The Active Interview. Qualitative

Research Methods Series 37. London: Sage.

Holt, J., Coates, C., Cotterill, D., Eastburn, S., Laxton, J., Mistry, H. and Young,

C. 2010. Identifying common competences in health and social care: An

example of multi-institutional and inter-professional working. Nurse

Education Today. 30(3), pp.264–270.

Hornby, S. and Atkins, J. 2000. Collaborative Care. Interprofessional,

Interagency and Interpersonal . Second Edition. Oxford: Blackwell Science.

Horner, N. 2009. What is Social Work? Context and Perspectives. Third

Edition. Exeter: Learning Matters.

Horobin, G. 1983. Professional Mystery: The Maintenance of Charisma in

General Medical Practice. In: Dingwall, R., and Lewis, P. (eds) The Sociology

of the Professions: Lawyers, Doctors and Others. Basingstoke: The

Macmillan Press Ltd, pp.84-105.

Howkins, E.J. and Ewens, A. 1999. How students experience professional

socialization. International Journal of Nursing Studies. 35(1), pp.41- 49.

280

Howkins, E.J. 2002. Accepting the surfing challenge: making sense of

collaboration. In: Howkins, E.J. and Thornton, C. (eds) Managing and

Leading Innovation in Healthcare. Edinburgh: Balliere Tindall, pp.126–149.

Hughes, E. 1971. The Sociological Eye. Chicago, Illinois: Atherton Inc.

Hugman, R. 1991. Power in caring professions. Basingstoke: The Macmillan

Press.

Humphris, D., and Macleod Clark, J. (n.d.) Embedding Interprofessional

Learning in Hampshire and the Isle of Wight: New Generation Project.

[Online] [Accessed 14 March 2014]. Available from:

http://eprints.soton.ac.uk/42914/1/070601NGP_Summary_paper.pdf

Jakobsen, F., Torben Baek, H. and Berit, E. 2011. Knowing more about the

other professions clarified my own profession. Journal of Interprofessional

Care. 25(6), pp.441–446.

Johnson, T.J. 1972. Professions and Power. Basingstoke: Macmillan.

Jones. R.J. 1991. Professionalization. In: Jones, R.J. (ed) Management in

Physiotherapy. Oxford: Radcliffe Medical Press, pp.11–17.

Kalet, A., Krackov, S. and Rey, M. 2002. Mentoring for a new era.

Developing as a professional – what it means to be a doctor. Academic

Medicine 77(11), pp.1171–1172.

Kaufman, D.M. and Mann, K.V. 2007. Teaching and Learning in Medical

Education: How Theory can Inform Practice. Edinburgh: Association for the

Study of Medical Education.

Kennedy, I. 2001. The Report of the Public Inquiry into children’s heart

surgery at the Bristol Royal Infirmary 1984-1995. Learning from Bristol.

London: HMSO. Crown Copyright. CM 5207(I).

Kent, R. 2001. Data Construction and Data Analysis for survey research.

Basingstoke: Palgrave.

281

Ker, J.S., Mole, L. and Bradley, P. 2003. Early introduction of

interprofessional learning: A simulated ward environment. Medical

Teacher. 37(3), pp.248–255.

Khalili, H., Orchard, C., Spence Laschinger, H.K. and Farah, R. 2013. An

interprofessional socialization framework for developing an

interprofessional identity among health professions students. Journal of

Interprofessional Care. 27(6), pp.448-453.

Kilminster, S. 2009. Recognising and bridging gaps: theory, research and

practice in clinical education. In: Delaney, C. and Molloy, E. Clinical

Education in the Health Professions. Chatswood: Elsevier Australia, pp.38-

50.

Kilminster, S. and Zukas, M. 2007. Shifting professional boundaries through

interprofessional education: a case of wishful thinking? In: RWL5

Conference December 2007, Cape Town.

Kilminster, S., Zukas, M., Quinton, N. and Roberts, T. 2010. Learning

practice? Exploring the links between transitions and medical

performance. Journal of Health Organization and Management. 24(6),

pp.556–570.

Kilminster, S., Hale, C., Lascelles, M., Morris, P., Roberts, T., Stark, P.,

Soweter, J. and Thistlethwaite, J. 2004. Learning for real life: Patient-

focused interporfessional workshops offer added value. Medical Education.

38(7), pp.717–726.

King, V. 2010. Evidencing impact of educational developments: the

‘influence wheel’ and its use in a CETL context. Journal of Further and

Higher Education. 34(1), pp.35–46.

King, S., Greidanus, E., Major, R., Loverso, T., Knowles, A., Carbonaro, M. and

Bahry, L. 2012. A cross-institutional examination of readiness for

interprofessional learning. Journal of Interprofessional Care 26(2), pp.108–

114.

282

Kirkpatrick, D.I. 1967. Evaluation of training. In: Craig, R. and Bittel, I. (eds)

Training and Development Handbook. New York: McGraw-Hill, pp.87–112.

Kogan, J.R. and Holmboe, E. 2013. Realizing the Promise and Importance of

Performance-Based Assessment. Teaching and Learning in Medicine: An

International Journal. 25(S1), S68–S74.

Koh, Y.H., Wong, M.L. and Lee, J.J. 2014. Medical students’ reflective writing

about a task-based learning experience on public health communication.

Medical Teacher. 36(2), pp.121-9.

Kvale, S. 1996. InterViews. An Introduction to Qualitative Research

Interviewing. London: Sage.

Kvale, S. and Brinkmann. S. 2009. InterViews. Learning the Craft of

Qualitative Research Interviewing. Second Edition. London: Sage.

Lake, F.R. 2004. Teaching on the run tips: doctors as teachers. The Medical

Journal of Australia. 180(8), pp.415–416.

Laming, W.H. 2003. The Victoria Climbié Inquiry. London: HMSO. Crown

Copyright. CM 5730.

Laming, W.H. 2009. The Protection of Children in England: A Progress

Report. London: The Stationery Office. Crown Copyright. HC 330.

Lane, J. 2001. A Social History of Medicine. Health, Healing and Disease in

England, 1750-1950. London: Routledge.

Langton, H. 2009. Interprofessional education in higher education

institutions: models, pedagogies and realities. In: Bluteau, P. and Jackson, A.

(eds) Interprofessional Education. Making it Happen. Basingstoke: Palgrave

Macmillan, pp.37–58.

Larkin, G. 1983. Occupational Monopoly and Modern Medicine. London:

Tavistock.

Larkin, H., Hitch, D., Watchorn, V., Ang, S. and Stagnitti, K. 2013. Readiness

for interprofessional learning: a cross-faculty comparison between

283

architecture and occupational therapy students. Journal of Interprofessional

Care. 27(5), pp.413–419.

Larsson, M., Aldegarmann, U. and Aarts, C. 2009. Professional role and

identity in a changing society: Three paradoxes in Swedish midwives’

experiences. Midwifery. 25(4), pp.373–381.

Lauffs, M., Ponzer, S., Saboonchi, F., Lonka, K., Hylin, U. and Mattiasson, A-C.

2008. Cross-cultural adaptation of the Swedish version of Readiness for

Interprofessional Learning Scale (RIPLS). Medical Education. 42(4),

pp.405–411.

Layzell, S. and Chahal, P. 2010. Evaluation of a multiprofessional learning

organisation: use of a questionnaire to investigate the learning experiences

of a group of undergraduate pharmacy students attached to primary care.

Education for Primary Care. 21(6), pp.376–384.

Lawler, S. 2008. Identity. Sociological Perspectives. Cambridge: Polity

Press.

Leathard, A. 1991. Going interdisciplinary. Nursing. 4(33), pp.9–11.

Leathard, A. 1994. Inter-professional developments in Britain. An

overview. In: Leathard, A. (ed) Going Inter-Professional. Working Together

for Health and Welfare. London: Routledge, pp.3-37.

Leathard, A. 2003. Introduction. In: Leathard, A. (ed) Interprofessional

Collaboration. From policy to practice in health and social care. London:

Routledge, pp.2-10.

Lewis, J. 2001. Older people and the health-social care boundary in the UK:

Half a century of hidden policy conflict. Social Policy and Administration.

35(4), pp.343–359.

Lindquist, I., Engardt, M., Garnham, L., Poland, F. and Richardson, B. 2006.

Physiotherapy students’ professional identity on the edge of working life.

Medical Teacher. 28(3), pp.270–276.

284

Lee, R.M. 2000. Unobtrusive Methods in Social Research. Understanding

Social Research Series. Buckingham: Open University Press.

Local Government and Housing Act 1989. (c.42). London: The Stationery

Office.

Lortie, D.C. 1966. Professional socialisation. In: Vollmer, H.M. and Mills,

D.M. (eds) Professionalisation. Englewood Cliffs, New Jersey: Prentice-Hall,

pp.98–101.

Lubinski, R. and Golper, L.A. 2007. Professional Issues: From Roots to

Reality. In: Lubinski, R., Golper, L.A.C. and Frattali, C.M. (eds) Professional

Issues in Speech-Language Pathology and Audiology. Third edition. New

York: Thompson.

Luecht, R.M., Madsen M.K., Taugher, M.P., Petterson, B.J. 1990. Assessing

professional perceptions: Design and validation of an interdisciplinary

education scale. Journal of Allied Health. Spring 19(2), pp.181–191.

Lymbery, M. 2006. United We Stand? Partnership Working in Health and

Social Care and the Role of Social Work in Services for Older People. British

Journal of Social Work. 36(7), pp1119-1134.

Lynch, D.C., Surdyk, P.M.. and Eiser, A. 2009. Assessing professionalism: a

review of the literature. Medical Teacher. 26(4), pp.366–373.

Macdonald, K. 1995. The Sociology of the Professions. London, Sage.

Machin, A.I., Machin, T. and Pearson, P. 2011. Maintaining equilibrium in

professional role identity: a grounded theory study of health visitors’

perceptions of their changing professional practice context. Journal of

Advanced Nursing. 68(7), pp.1526-1537.

Machin, A.I. and Pearson, P. 2013. Health visitors’ interprofessional

working experiences: Implications for their collaborative public health role.

Journal of Health Visiting. 1(1): pp.31-38.

285

Mackay, L. 1998. Nursing: will the Idea of Vocation Survive? In: Abbott, P.

and Meerabeau, L. (eds) The Sociology of the Caring Professions. Second

Edition. Abingdon: Routledge, pp.54–72.

Malcolm, J. and Zukas, M. 2009. Making a mess of academic work:

experience, purpose and identity. Teaching in Higher Education. 14(5),

pp.495–506.

Martin-Rodriguez, L.S., Beaulieu, M-D., D’Amour, D. and Ferrada-Videla, M.

2005. The determination of successful collaboration: a review of theoretical

and empirical studies. Journal of Interprofessional Care. 19(2), pp.132-147.

Mason, J. 2006. Mixing methods in a qualitatively driven way. Qualitative

Research. 6(1), pp.9-25.

Mayers, P., Alperstein., Duncan, M., Olckers, L and Gibbs, T. 2006. Not just

another multi-professional course! Part 2: Nuts and bolts of designing a

transformed curriculum for multi-professional learning. Medical Teacher.

28(2), pp.152–157.

McDonald, R. 2004. Individual identity and organisational control:

empowerment and modernisation in a primary care trust. Sociology of

Health and Illness. 26(7), pp.925-950.

McFadyen, A.K., Webster, V., Strachan, K, Figgins, E., Brown, H. and

McKechnie, J. 2005. The Readiness for Interprofessional Learning Scale: A

possible more stable sub-scale model for the original version of RIPLS.

Journal of Interprofessional Care. 19(6), pp.595–603.

McFadyen, A.K., Webster, V. S., and Maclaren, W. M. 2006. The test-retest

reliability of a revised version of the Readiness for Interprofessional

Learning Scale (RIPLS). Journal of Interprofessional Care. 20(6), pp.633–

639.

McKenna, H.P., Hasson, F. and Keeney, S. 2004. Patient safety and quality of

care: the role of the health care assistant. Journal of Nursing Management.

12(6), pp.452–459.

286

McPherson, K., Headrick, L. and Moss, F. 2001. Working and learning

together: good quality care depends on it, but how can we achieve it?

Quality in Health Care. 10(Suppl. II), pp.ii46–ii53.

Mead, G.H. 1934. Mind, Self and Society. Edited by Charles W. Morris.

Chicago: University of Chicago Press.

Meerabeau, L. 1998. Project 2000 and the Nature of Nursing Knowledge. In:

Abbott, P. and Meerabeau, L. (eds) The Sociology of the Caring Professions.

Second Edition. Abingdon: Routledge, pp.82–105.

Mendelson, D. 2011. Transformations of working identities. Labour and

the self. In: Elliott, A. (ed) Routledge Handbook of Identity Studies.

Abingdon: Routledge, pp.151–169.

Miller, C., Woolf, C. and Mackintosh, N. 2006. Evaluation of Common

Learning Pilots and Allied Health Professions First Wave Sites. Final Report.

London: Department of Health. Cm0160050.

Millerson, G. 1964. The Qualifying Associations: A Study in

Professionalization. London: Routledge and Kegan Paul.

Mishler, E.G. 1986. Research Interviewing. Context and narrative.

Cambridge: Harvard University Press.

Monrouxe, L. 2010. Identity, identification and medical education: why

should we care? Medical Education. 44(1), pp.40–49.

Morison, S.L. and Stewart, M.C. 2005. Developing interprofessional

assessment. Learning in Health and Social Care. 4(4), pp.192–202.

Moore, W.E. 1970. The Professions Roles and Rules. New York: Russell Sage.

Morison, S., Boohan, M., Moutray, M. and Jenkins, J. 2004. Developing pre-

qualification inter-professional education for nursing and medical

students: sampling student attitude to guide development. Nurse Education

in Practice. 4(1), pp.20–29.

287

Murphy, C. 2007. Death of the doctor’s white coat. BBC News. [Online]. 17th

September. [Accessed 18 June 2013]. Available from:

http://news.bbc.co.uk/1/hi/health/6998877.stm

National Health Service and Community Care Act 1990. (c.19). London: The

Stationery Office.

Needham, C. 2011. Personalising Public Services. Understanding the

personalisation narrative. Bristol: The Policy Press.

Neuman, W.L. 2003. Social Research Methods: Qualitative and Quantitative

Approaches. 5th Edition. Boston: Allyn and Bacon.

Newton, M. and Chaney, J. 1996. Professional image: endorsed of inhibited

by attire? Journal of Professional Nursing. 12(4), pp.240–244.

Niemi, A. and Paasivaara, L. 2007. Meaning contents of radiographers’

professional identity as illustrated in a professional journal – A discourse

analytic approach. Radiography. 13(4), pp.258–264.

Nolan, M. 1995. Towards an ethos of interdisciplinary practice. British

Medical Journal. 311, pp.305–307.

Norcini, J. and Burch, V. 2007. Workplace-based assessment as an

educational tool. Medical Teacher. 29(9), pp.855–871.

Nursing and Midwifery Council. 2010. The Code. Standards of conduct,

performance and ethics for nurses and midwives. London: Nursing and

Midwifery Council.

Oandasan, I. and Reeves, S. 2005. Key elements of interprofessional

education. Part 2: Factors, processes and outcomes. Journal of

Interprofessional Care. 19(2), pp.39–48.

O’Connell Davidson, J. 2005. Children in the Global Sex Trade. Cambridge:

Polity Press.

288

O’Halloran, C., Hean, S., Humphris, D. and Macleod Clarke, J. 2006.

Developing common learning: The New Generation Project undergraduate

curriculum model. Journal of Interprofessional Care. 20(1), pp.12–28.

O’Neill, B.J. and Wynes, M.A. 2005. Learning about interprofessional

education: Student voices. Medical Teacher. 27(5), pp.433–438.

Olckers, L., Gibbs, T.J. and Duncan, M. 2007. Developing health science

students into integrated health professionals: a practical tool for learning.

BMC Medical Education. 7(45). [Online]. [Accessed 16 June 2013]. Available

from: http://www.biomedcentral.com/1472-6920/7/45

Oliver, M. 2010. Setting the Scene: E-Learning and the Evolution of Roles

and Practices in Post-Compulsory Education. In: Bromage, A., Clouder, L.,

Thistlethwaite, J. and Gordon, F. (eds) Interprofessional e-learning and

collaborative work: Practices and technologies. Pennsylvania: IGI Global,

pp.34–45.

Oppenheim, A.N. 1992. Questionnaire Design, Interviewing and Attitude

Measurement. London: Continuum.

Owen, J., Brashers, T., Peterson, C., Blackhall, L. and Erickson, J. 2012.

Collaborative care best practice models: a new educational paradigm for

developing interprofessional education (IPE) experiences. Journal of

Interprofessional Care. 26(2), pp.153–155.

Parsell, G., and Blight, J. 1998. Educational principles underpinning

successful shared learning. Medical Teacher. 20(6), pp.522–529.

Parsell, G., Spalding, R. and Bligh, J. 1998. Shared goals, shared learning:

Evaluation of a multi-professional course for undergraduate students.

Medical Education. 32(3), pp.304–311.

Parsell, G. and Bligh, J. 1999. The development of a questionnaire to assess

the readiness for health care students for interprofessional learning

(RIPLS). Medical Education. 33(2), pp95–100.

Pawson, R. and Tilley, N. 1997. Realistic Evaluation. London: Sage.

289

Pearson, A., Baker, H., Walsh, K. and Fitzgerald, M. 2001. Contemporary

nurses; uniforms – history and traditions. Journal of Nursing Management.

9(3), pp.147–152.

Pearson, P., Steven, A. and Dickinson, C. 2006. Learning Together in

Practice. Newcastle: Newcastle Upon Tyne.

Pearson, P., Dickinson, C., Steven, A. and Dawson, P. 2007. Case Study –

Towards a common Goal: Developing practice-based interprofessional

education in North East England. In: Occasional Paper No 8 - Piloting

Interprofessional Education: Four English Case Studies. London: Higher

Education Academy. [Online] [Accessed 15 March 2014] Available from:

http://www.health.heacademy.ac.uk/

Pelling, S., Kalen, A., Hammar, M. and Wahlström, O. Preparation for

becoming members of health care teams: findings from a 5-year evaluation

of a student interprofessional training ward. Journal of Interprofessional

Care. 25(5), Pp.328-328.

Peloquin, S.M., Cavazos, H.,Marion, R., Stephenson, K.S. and Pearrow, D.

2007. Report on an Interdisciplinary Program for Allied Health. Education

for Health. 20(3), p136.

Perkin, H. 2002. The Rise of Professional Society. England since 1880. Third

Edition. London: Routledge.

Pirrie, A., Hamilton, S. and Wilson, V. 1999. Multidisciplinary education:

some issues and concerns. Educational Research. 41(3), pp.301–314.

Pfadenhauer, M. 2009. At Eye-Level: The Expert Interview – a Talk between

Expert and Quasi-expert. In: Bogner, A., Littig, B. and Menz, W. Interviewing

Experts. Research Methods Series. Basingstoke: Palgrave Macmillan, pp.81-

97.

Pollard, K.C. 2011. How midwives’ discursive practices contribute to the

maintenance of the status quo in English maternity care. Midwifery. 27(5),

Pp612–619.

290

Pollard, K.C. 2008. Non-formal learning and interprofessional collaboration

in health and social care: the influence of the quality of staff interaction on

student learning about collaborative behaviour in practice placements.

Learning in Health and Social Care. 7(1), pp 12 – 26.

Pollard, K.C. and Miers, M.E. 2008. From students to professionals: Results

of a longitudinal study of attitudes to pre-qualifying collaborative learning

and working in health and social care in the United Kingdom. Journal of

Interprofessional Care. 22(4), pp.399–416.

Ponzer, S., Hylin, U., Kusoffsky, A., Lauffs, M., Lonka, K., Mattiasson, A.C. and

Nordström, G. 2004. Interprofessional training in the context of clinical

practice: goals and students’ perceptions on clinical education wards.

Medical Education. 38(7), Pp.547-560.

Poovey, M. 1989. Uneven developments: The Ideological Work of Gender in

Mid-Victorian England. London: Virago.

Porter, S., Crozier, K., Sinclair, M. and Kernohan, W.G. 2007. New

midwifery? A qualitative analysis of midwives’ decision-making strategies.

Journal of Advanced Nursing. 60(6), pp.525–534.

Powell, S. and Scott, L. 2013. An evaluation of two practice based

interprofessional initiatives for undergraduate healthcare students in North

East England. Newcastle: CETL4HealthNE.

Pratt, M.G., Rockmann, K.W. and Kauffman, J.B. 2006. Constructing

professional identity: The role of work and identity learning cycles in the

customization of identity among medical residents. Academy of

Management Journal. 40(2), pp.235-262.

Propp, V. 1975. Morphology of the folktale. Texas: University of Texas

Press.

Pulman, A., Scammell, J. and Matin, M. 2009. Enabling interprofessional

education: The role of technology to enhance learning. Nurse Education

Today. 29(2), pp.232–239.

291

QAA. 2006. Statement of Common Purpose for Subject Benchmarks for

Health and Social Care. Gloucester: Quality Assurance Agency for Higher

Education in England.

Rabøl, L.I., Østergaard, D. and Mogensen, T. 2010. Outcomes of classroom-

based eam training intervention for multiprofessional hospital staff. A

systematic review. Quality and Safety in Health Care. 19(6), e27.

Reeves, S., Freeth, D., McCrorie, P. and Perry, D. 2002. ‘It teaches you what

to expect in the future…’: interprofessional learning on a training ward for

medical, nursing, occupational therapy and physiotherapy students.

Medical Education. 36(4): Pp.337-344.

Reeves, S., Goldman, J., and Oandasan, I. 2007. Key factors in planning and

implementing interprofessional education in health care settings. Journal of

Allied Health. 36(4), Pp.231–235.

Reeves, S., Zwarenstein, M., Barr, H., Freeth, D., Hammick, M. and Koppel, I.

2008. Interprofessional education: effects on professional practice and

healthcare outcomes. Cochrane Database of Systematic Reviews 2008. Issue

1. Art. No.: CD002213. DOI: 10.1002/14651858.CD002213.pub2

Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Koppel, I. and

Hammick, M. 2010a. The effectiveness of interprofessional education: Key

findings from a new systematic review. Journal of Interprofessional Care.

24(3), pp.230–241.

Reeves, S., MacMillan, K. and van Soeren, M. 2010b. Leadership of

interprofessional health and social care teams: A socio-historical analysis.

Journal of Nursing Management. 18(3), pp.258–264.

Reid, R., Bruce, D., Allstaff, K. and McLernon, D. 2006. Validating the

Readiness for Interprofessional Learning Scale (RIPLS) in the postgraduate

context: are health care professionals ready for IPL? Medical Education.

40(5), pp.415–422.

292

Reissman, C.K. 2008. Narrative Methods for the Human Sciences. London:

Sage.

Rice, K., Zwarenstein, M., Gotlib Conn, L., Kenaszchuk, C., Russell, A. and

Reeves, S. 2010. An intervention to improve interprofessional collaboration

and communications: A comparative qualitative study. Journal of

Interprofessional Care. 24(4), pp.350–361.

Ricoeur, P. 1991. Life in quest of narrative. In: Wood, D. (ed) On Paul

Ricoeur: Narrative and Interpretation. London: Routledge.

Roberts, B. 2002. Biographical Research. Understanding Social Research

Series. Buckingham: Open University Press.

Roberts, L. 2010. Shifting Identities: An investigation into student and

novice teachers’ evolving professional identity. Journal of Education for

Teaching: International research and pedagogy. 26(2), pp.185–186.

Roberts, T.E. 2010. Reflections on leading and managing a large educational

project. [Online]. [Accessed 15 July 2014]. Available from:

http://www.alps-cetl.ac.uk/documents/ALPSManagement.pdf

Robertson, V.J., Oldmeadow, L.B., Cromie, J.E. and Grant, M.J. 2003. Taking

charge of change: A new career structure in physiotherapy. Australian

Journal of Physiotherapy. 49(4), pp.229–231.

Robson, M. and Kitchen, S.S. 2007. Exploring physiotherapy students’

experiences of interprofessional collaboration in the clinical setting: a

critical incident study. Journal of Interprofessional Care. 21(1), pp.95–109.

Rosenfeld, D., Oandasan, I. and Reeves, S. 2011. Perceptions versus reality:

a qualitative study of students’ expectations and experiences of

interprofessional education. Medical Education. 45(5), pp.471–477.

Rosnow, R.L. and Rosenthal, R. 1976. The volunteer subject revisited.

Australian Journal of Psychology. 28(2), pp.97-108.

293

Ross, A., King, N. and Firth, J. 2005. Interprofessional Relationships and

Collaborative Working: Encouraging Reflective Practice. The Online Journal

of Issues in Nursing. 10(1), Manuscript 3.

Rossman, G.B. and Rallis, S.F. 2003. Learning in the Field. An Introduction to

Qualitative Research. Second Edition. London: Sage.

Salfi, J., Solomon, P., Allen, D., Mohaupt, J. and Patterson, C. 2012.

Overcoming all obstacles: a framework for embedding interprofessional

education into a large, multisite Bachelor of Nursing program. Journal of

Nursing Education. 51(2), pp.106–110.

Salter, B. 1998. The Politics of Change in the Health Service. Basingstoke:

Macmillan.

Samuel, M. 2013. What social workers need to know about the new NHS.

[Online]. [Accessed 02 November 2013]. Available from:

http://www.communitycare.co.uk/

Sapsford, R. 1999. Survey Research. London: Sage.

Saunders, M., Machell, J., Silliams, S., Allaway, D., Spencer, A., Ashwin, P.,

Trowler, P., Fanghanel, J., Morgan, L.A. and McKee, A. 2008. 2005 – 2010

Centres of Excellence in Teaching and Learning programme. Formative

evaluation report to HEFCE by the Centre for Study in Education and

Training / Institution of Educational Technology. [Online]. [Accessed 24

February 2014]. Available from: http://eprints.lancs.ac.uk/

Scholes, J. 2008. Guest Editorial: Coping with the professional identity

crisis: Is building resilience the answer? International Journal of Nursing

Studies. 45(7), pp.975-978.

Scholes, J. and Vaughan, B. 2002. Cross-boundary working: implications for

the multiprofessional team. Journal of Clinical Nursing. 11(3), pp.399–408.

Scott, J. 2002. Doing social research. In: Marsh, E. (ed). Theory and Practice

in Sociology. Essex: Pearson Education, pp.3-25.

294

Scott, W.R. 2001. Institutions and Organizations. Second edition. California:

Sage.

Seabrook, M. 1998. Overcoming tribalism. Nursing Standard. 12(20), pp.23-

24.

Shaw, K. and Timmons, S. 2010. Exploring how nursing uniforms influence

self image and professional identity. Nursing Times. 106(10), pp.21–23.

Sheldon, M., Cavanaugh, J.T., Croninger, W., Osgood, W., Robnett, R., Seigle, J.

and Simonsen, L. 2012. Preparing rehabilitation healthcare providers in the

21st century: Implementation of interprofessional education through an

academic-clinical site partnership. Work: Journal of Prevention, Assessment

and Rehabilitation. 41(3), pp.269–275.

Shove, E. 2012. The Dynamics of Social Practice. In: Shove, E., Pantzar, M.

and Watson, M. (eds) The Dynamics of Social Practice. Everyday Life and

How it Changes. London: Sage.

Silverman, D. 2010. Doing Qualitative Research. Third Edition. London:

Sage.

Simmons, R. 2008. Questionnaires. In: Gilbert, N. (ed) Researching Social

Life. Third Edition. London: Sage.

Smith, S. and Roberts, P. 2005. An investigation of occupational therapy and

physiotherapy roles in a community setting. International Journal of

Therapy and Rehabilitation. 12(1), pp21-29.

Smyth, M., and Williamson, E. 2004. Researchers and their ‘subjects’. Ethics,

power, knowledge and consent. Bristol: The Policy Press.

Solomon, P., Baptiste, S., Hall, P., Luke, R., Orchard, C., Rukholm, E., Carter,

L., King, S and Damiani-Taraba, G. 2010. Students’ perceptions of

interprofessional learning through facilitated online learning modules.

Medical Teacher. 32(9), e391–e398.

295

Somers, M.R., and Gibson, G.D. 1994. Narrative and Social Identity. In:

Calhoun, C. (ed) Social Theory and the Politics of Identity. Oxford: Blackwell,

pp.37–99.

Spilsbury, K. and Meyer, J. 2004. Use, misuse and non-use of health care

assistants: understanding the work of health care assistants in a hospital

setting. Journal of Nursing Management. 12(6). Pp.411–418.

Spragley, F. and Francis, K. 2006. Nursing uniforms: professional symbol or

outdated relic? Nursing Management. 37(10). Pp.55–58.

SQW. 2011. Summative evaluation of the CETL Programme. Final Report by

SQW to HEFCE and DEL. [Online]. [Accessed 04 February 2014]. Available

from: https://www.hefce.ac.uk/

Tajfel, , H. 1982. Instrumentality, identity and social comparisons. In: Tajfel,

H. (ed) Social identity and intergroup relations. Cambridge: Cambridge

University Press, pp.483–507.

Thannhauser, J., Russell-Mayhew, S. and Scott, C. 2010. Measure of

interprofessional education and collaboation. Journal of Interprofessional

Care. 24(4), pp.336-349.

Thistlethwaite, J.E. and Nisbet, G. 2011. Preparing educators for

interprofessional learning: rationale, educational theory and delivery. In:

Kitto, S,. Chesters, J.,Thistlethwaite, J.E. and Reeves, S. (eds) Sociology of

Interprofessional Health Care Practice: Critical Reflections and Concrete

Solutions. New York: Nova Science Publishers, pp.169–184.

Thistlethwaite, J. 2012. Interprofessional education: a review of context,

learning and the research agenda. Medical Education. 46(1), pp.58–70.

Thompson, M. and Ryan, A. 1996. The influence of fieldwork on the

professional socialisation of occupational therapy students. British Journal

of Occupational Therapy. 59(2), pp.65–70.

296

Thornley, C. 2001. A question of competence? Re-evaluating the roles of

the nursing auxiliary and health care assistant in the NHS. Journal of

Clinical Nursing. 9(3), pp.451–458.

Timmons, S. and East, L. 2011. Uniforms, status and professional

boundaries in hospital. Sociology of Health and Illness. 33(7), pp1035–

1049.

Tschudin, V. 1999. Nurses Matter. Reclaiming our professional identity.

Basingstoke: Macmillan.

Tunstall-Pedoe, S., Rink, E. and Hilton, S. 2003. Student attitudes to

undergraduate interprofessional education. Journal of Interprofessional

Care. 17(2), pp.161–172.

Turner, C.F. and Martin, E. 1984. Surveying subjective phenomena. New

York: Russell Sage.

Vehovar, V. and Manfreda, K.L. 2008. Overview: Online Surveys. In:

Fielding, N., Lee, R.M. and Blank, G. (eds) The Sage Handbook of Online

Research Methods. London: Sage.

Wackerhausen, S. 2009. Collaboration, professional identity and reflection

across boundaries. Journal of Interprofessional Care. 23(5), pp.455–473.

Waddington, K. 2011. An Introduction to the Social History of Medicine.

Europe Since 1500. Basingstoke: Palgrave Macmillan.

Wahlström, O. and Sandén, I. 1998. Multiprofessional training ward at

Linköping University: early experience. Education for Health. 11, pp.225–

231.

Walby, S. 1990. Theorising Patriarchy. Oxford: Blackwell.

Walker, J. and Almond, P. 2010. Interpreting Statistical Findings. A guide

for health professionals and students. Maidenhead: Open University Press.

Warner, J. 2013. Social work, class politics and risk in the moral panic over

Baby P. Health, Risk and Society. 15(3), pp.217–233.

297

Waterston, R. 2011. Interaction in online interprofessional education case

discussions. Journal of Interprofessional Care. 25(4), pp.272–279.

Watts, F., Lindqvist, S., Pearce, S., Drachler, M. and Richardson, B. 2007.

Introducing a post-registration interprofessional learning programme for

healthcare teams. Medical Teacher. 29(5), pp.443–449.

Webb, E.J., Campbell, D.T., Schwartz, R.D. and Sechrest, L. 1966. Unobtrusive

Measures: Nonreactive Research in the Social Sciences. Dallas: Houghton

Mifflin.

Wenger, E. 1998. Communities of Practise, Learning, Meaning and Identity.

Cambridge: Cambridge University Press.

Whitehead, C. 2007. The doctor dilemma in interprofessional education

and care: how and why will physicians collaborate? Medical Education.

41(10), pp.1010-1016.

Wickstead, J. H. 1948. The Growth of a Profession. London: Edward Arnold

& Co.

Wilcock, A.A. 2002. Occupation for health, Vol. 2: A journey from prescription

to self health. London: College of Occupational Therapists.

Wilding, P. 1982. Professional Power and Social Welfare. London: Routledge

and Kegan Paul.

Wilhelmsson, M., Pelling, S., Ludvigsson, J., Hammar, M., Dahlgren, L-O. and

Faresjö, T. 2009. Journal of Interprofessional Care. 23(2), pp.121-133.

Williams, A. and Sibbald, B. 1999. Changing roles and identities in primary

health care: exploring a culture of uncertainty. Journal of Advanced Nursing.

29(3), pp.737–745.

Williams, J. and Lakhani, N. 2010. E-learning for interprofessional

education. Journal of Interprofessional Care. 24(2), pp.201–203.

298

Williamson, G.R., Callaghan, L., Whittlesea, E., Mutton, L and Heath, V. 2011.

Placement Development Teams and interprofessional education with

healthcare students. 20(15-16), pp.2305–2314.

Witz, A. 1992. Professions and patriarchy. London: Routledge.

Woodward, K. 2002. Understanding Identity. London: Hodder Education.

World Health Organization 1988. Learning together to work together for

health. Report of a WHO Study Group on Multiprofessional Education of

Health Personnel: the Team Approach. World Health Organization

Technical Report Series 769. Geneva: WHO.

World Health Organization 2010. Framework for action on interprofessional

education and collaborative practice. Department of Human Resources for

Health. [Online]. [Accessed 24 March 2013]. Available from:

http://www.who.int/hrh/resources/framework_action/en/

Wright, D.B. 2002. First Steps in Statistics. London: Sage.

Yin, R.K. 2009. Case Study Research. Design and Methods. Fourth Edition.

London: Sage

Zukas, M. 2012. Research Paradigms in Medical Education. Medical

Education Research Development 5th Annual Yorkshire Meeting. 1 October

2012, Leeds.

Zwarenstein, M., Reeves, S., Barr, H., Hammick, M., Koppel, I. and Atkins, J.

2000. Interprofessional education: effects on professional practice and

health care outcomes. Cochrane Database of Systematic Reviews 2000 Issue

3.

Zwarenstein, M., and Reeves, S. 2006. Knowledge translation and

interprofessional collaboration: Where the rubber of evidence-based care

hits the road of teamwork. The Journal of Continuing Education in the

Health Professions. 26(1), pp.46–54.

299

Glossary

ALPS Assessment and Learning in Practice Settings

BASW British Association of Social Workers

BMA British Medical Association

BOS Bristol Online Surveys

CAIPE Centre for the Advancement of Interprofessional Education

CBA Cost Benefit Analysis

CBL Case-based learning

CCBPM Collaborative Care Best Practice Models

CETL Centre for Excellence in Teaching and Learning

CFP Common Foundation Programme

CIPW Creating an Interprofessional Workforce Programme

CL Cooperative Learning

CLPNE Common Learning Programme in the North East

CQC Care Quality Commission

CUILU Combined Universities Interprofessional Learning Unit

DH Department of Health

GCC General Chiropractic Council

GDC General Dental Council

GMC General Medical Council

GOC General Optical Council

GOsC General Osteopathic Council

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GPC General Pharmaceutical Council

GSCC General Social Care Council

H&SC Health and Social Care

HCA Healthcare Assistant

HCPC Health and Care Professions Council

HE Higher Education

HEFCE Higher Education Funding Council for England

HEI Higher Education Institution

HSE Health and Safety Executive

IEPS Interdisciplinary Education Perception Scale

ILP Interprofessional Learning in Practice

IPE Interprofessional Education

IPW Interprofessional Working

IRAS Integrated Research Application System

LTHT Leeds Teaching Hospitals NHS Trust

MDT Multi Disciplinary Team

MSF Multi-Source Feedback

NHS National Health Service

ODP Operating Department Practice

OT Occupational Therapy

PBL Problem-based learning

PSIG Partner Site Implementation Group

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PSRB Professional, Statutory, Regulatory Bodies

QAA Quality Assurance Agency

QABME Quality Assurance of Basic Medical Education

RIPLS Readiness of healthcare students for interprofessional

learning

SIT Social Identity Theory

SHA Strategic Health Authority

SLT Speech and Language Therapy

UK United Kingdom

WHO World Health Organisation

YHSHA Yorkshire and the Humber Strategic Health Authority

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Appendix 1: Research Protocol submitted to IRAS

27th April 2009 Version 1 REC Reference: 09/HI306/58

RESEARCH PROJECT PROTOCOL Study title: Does interprofessional education and working have any impact on the formulation of perceptions of professional identity and organisational culture? Researcher: Viktoria Joynes (PhD student) Supervisors: Trudie Roberts, Sue Kilminster, Paul Armstrong

Overview of the Project

The purpose of this research is to explore the experiences and opinions of all health and social care staff towards interprofessional education (IPE), interprofessional working and their own professional identity. The work of the Assessment and Learning in Practice Settings (ALPS) Centre for Excellence in Teaching and Learning (CETL) will provide a case study with which to explore these issues in depth.

For the most part, existing work on IPE focuses on student attitudes towards IPE programmes. For IPE to achieve its aims however, it needs to be taught effectively, which means that staff (both academic and practice) need to be engaged with IPE and the reasons for teaching it. Additionally, as health and social care students learn a lot from their placement experiences, the attitudes of practice staff are important because of the potential influence this will have on student opinion. A greater understanding of staff attitudes towards IPE is therefore required in order to understand if staff attitudes have any implications for implementation of IPE programmes.

It is therefore hoped that the results of the study will include recommendations for the way in which IPE is introduced into health and social care curriculums in the future.

Research Objectives and Questions

The principal research objective is to explore the experiences of health and social care staff with reference to interprofessional education and working. This is being done in order to investigate whether experiences of interprofessional education and working have any impact on perceptions of professional identity and organisational structure. The issues raised will be explored with reference to existing theories of professional identity and organisational culture.

The research questions are as follows:

1. What are the opinions of health and social care staff about IPE and interprofessional working?

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2. Do health and social care staff conceptualise all health care delivery as ‘interprofessional?

3. Can – and do – experiences of teaching IPE to students change the way in which health and social care staff interact with other professions?

4. How do health and social care staff describe their own professional identity, and the professional identity of other H&SC staff?

Methodology

The research for this project will be carried in out in two phases. The ethical approval submitted refers to both phases of the research. Throughout the application the research is referred to as Phase 1 or 2:

Phase 1. Quantitative questionnaires to be completed online or on paper

Phase 2. Qualitative semi-structured interviews (n = 15).

Phase 1: This quantitative questionnaire will ask respondents about their professional background, and ask them to rank statements about their opinions of professional identity and interprofessional education and working.

This is an exploratory study, and participants will ‘self select’ to take part in the research by completing a questionnaire online by clicking in a link in an email, or by filling out a paper questionnaire. As such it is not possible to say how many people will take part in this questionnaire, but a number in excess of 200 is hoped for.

Any qualified, practicing member of health and social care staff in England is eligible to take part in phase 1 the study.

The data from phase 1 of the research will be analysed in terms of looking for trends in opinion across participants and exploring if there are any differences of statistical significance between respondent groups (particularly professional groupings).

Phase 2: This qualitative face-to-face interview will cover the same themes as those raised in phase 1 of the research but in more depth, with more focus on personal experiences of participants in terms of interprofessional education. It will also take the ALPS CETL as a case study and ask respondents about their perceptions of the impact of ALPS as a large-scale IPE programme. Obviously the pre-requisite for phase 2 of the research is a level of familiarity with the ALPS programme, and as such potential respondents will be identified by the researcher. As the ALPS programme is based in West Yorkshire, the chosen research site for this research is the Leeds Teaching Hospitals trust, where the majority of staff who will have come in to contact with ALPS will be based. For similar reasons Social Work staff from Local Authorities in West Yorkshire will be asked to participate in this phase of the research.

Interviews will last approximately 45 minutes and will take place at a location of the participants’ choice. Each interview will be audio recorded using a digital voice recorder. Interviews will then be transcribed by the researcher and the results analysed. Responses will be grouped and coded, and then subject to thematic analysis.

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Participants do not have to taken part in phase 1 of the research in phase 2, or vice versa. However should participants be eligible to take part in both phases of the research they will be able to do so.

Recruitment

Phase 1: As this survey is exploratory in nature, potential participants will not be ‘identified’, rather they will be recruited via email or web adverts or by being given the opportunity to fill out a paper version of the survey. As such, participants will ‘self-select’ to take part in this phase of the research. Adverts for the online survey will be placed on online forums and online and paper bulletins (such as the Practice Learner Facilitators Forum). Potential participants will be able to access the survey directly from a link placed in these adverts. In addition the researcher will send out email adverts to colleagues and ask them to forward the link to any health and social care staff who may be interested in taking part.

A similar method will be used to distribute paper a version of the survey, with the researcher giving copies to colleagues and asking them to advertise the survey to health and social care staff who may be interested I taking part in the survey.

Phase 2: As outlined in the Methodology section, participants for phase 2 will need to have some degree of familiarity with the work of the ALPS CETL. Potential participants will therefore be identified by the researcher (who works with ALPS herself) as having some degree of familiarity with ALPS. They will then be sent an email to invite them to take part in the research. Participants will express their interest in taking part in the research by sending a return email.

It will be made clear to potential participants in both phase 1 and phase 2 of the research that their participation is entirely voluntary.

Expenses

No incentives are being offered to take part in this research. Participants in phase 1 will not incur any costs to take part in the research. However it is possible that participants in phase 2 will have had to travel to take part in an interview. In the instance that these participants do incur travel costs to take part in an interview these will be reimbursed.

Consent

Phase 1: Phase 1 participants will be asked to tick a box either on the paper or online questionnaire to show that they have given their consent to take part in the research.

Phase 2: Participants in phase 2 of the research will be asked to sign a consent form at the beginning of their interviews to show that they have given their consent to take part in the research and that they are happy for their interviews to be audio-recorded and then transcribed.

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Confidentiality

Phase 1: No identifying information is being recorded as part of phase 1 of the research. As such all survey results will remain anonymous and there will be no way to identify respondents from their survey answers.

Phase 2: Transcriptions of the recorded interviews will be stored using pseudonyms. These pseudonyms will be used when quoting in subsequent papers. No personal information about respondents will be stored with the data itself, and the contact details of those who do take part will be kept on a secure server at the University of Leeds until no longer needed (at then end of the study), when they will be destroyed.

Dissemination of results

The main purpose of this data collection is for a PhD study, and as such the results of the study will appear in full as part of the resulting PhD thesis. Additional papers covering aspects of the research may also be produced for conferences and journals.

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Appendix 2: Approval letter received from Leeds East

Research Ethics Committee

Leeds (East) Research Ethics Committee

Room 5.2, Clinical Sciences Building St James's University Hospital

Beckett Street Leeds

LS9 7TF

Telephone: 0113 2065652 Facsimile: 0113 2066772

12 June 2009

Ms Viktoria Joynes ALPS Research Officer ALPS CETL University of Leeds

Room 7.09 Worsley Building LS2 9NL Dear Ms Joynes

Study Title: Does interprofessional education and working have any impact on the formulation of perceptions of professional identity and organisational culture?

REC reference number: 09/H1306/58

Protocol number: 1

The Research Ethics Committee reviewed the above application at the meeting held on 2 June 2009. Thank you for attending to discuss the study. Ethical opinion At the meeting, members asked whether you expected professional and inter professional identity to be dependent or independent variables. Members were happy with your explanation that IPE had the potential to impact on perceptions of professional identity and the aim of the study was to investigate whether there was a relationship between the two. The method for choosing staff for interview was queried. You explained that

307

you would know the people involved in IPE locally. A decision would be made in conjunction with your supervisors after the completion of Phase I on which professions would be best targeted; you particularly wished to include medical staff and social workers. Members were satisfied with this approach. The members of the Committee present gave a favourable ethical opinion of the above research on the basis described in the application form, protocol and supporting documentation, subject to the conditions specified below.

Ethical review of research sites The favourable opinion applies to all NHS sites taking part in the study, subject to management permission being obtained from the NHS/HSC R&D office prior to the start of the study (see “Conditions of the favourable opinion” below). Conditions of the favourable opinion The favourable opinion is subject to the following conditions being met prior to the start of the study. Management permission or approval must be obtained from each host organisation prior to the start of the study at the site concerned.

For NHS research sites only, management permission for research (“R&D approval”) should be obtained from the relevant care organisation(s) in accordance with NHS research governance arrangements. Guidance on applying for NHS permission for research is available in the Integrated Research Application System or at http://www.rdforum.nhs.uk. Where the only involvement of the NHS organisation is as a Participant Identification Centre, management permission for research is not required but the R&D office should be notified of the study. Guidance should be sought from the R&D office where necessary. Sponsors are not required to notify the Committee of approvals from host organisations. After discussing the study further after you had left the room, members suggested that the study should either be confined to participants experiences, or if a comparative element was included, you should make strenuous attempts to ensure that it was clear whether participants had, or had not, received IPE. Please note that this is a suggestion rather than a condition of the favourable opinion. It is responsibility of the sponsor to ensure that all the conditions are complied with before the start of the study or its initiation at a particular site (as applicable). Approved documents

The documents reviewed and approved at the meeting were:

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Document Version Date

Covering Letter 28 April 2009

Application 24 April 2009

Investigator CV 27 April 2009

CV of Trudie Elizabeth Roberts

Letter of Invitation: Phase 1 - Paper Survey

1 27 April 2009

Letter of Invitation: Phase 1 - Online Survey

1 27 April 2009

Participant Information Sheet: Phase 1: Online or Paper Survey

2 27 April 2009

Letter of Invitation: Phase 2 - Face to Face Interview

1 27 April 2009

Participant Consent Form: Phase 2 - Face to Face Interview

2 27 April 2009

Participant Information Sheet: Phase 2 - Face to Face Interview

2 27 April 2009

Interview Schedules/Topic Guides

3 27 April 2009

Questionnaire: Phase 1: Double sided format to be presented to respondents

7 27 April 2009

Questionnaire: Phase 1: Single sided format

7 27 April 2009

Letter from Sponsor 24 April 2009

Compensation Arrangements

02 October 2008

Protocol 1 27 April 2009

Membership of the Committee The members of the Ethics Committee who were present at the meeting are listed on the attached sheet. Statement of compliance The Committee is constituted in accordance with the Governance Arrangements for Research Ethics Committees (July 2001) and complies fully

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with the Standard Operating Procedures for Research Ethics Committees in the UK. After ethical review

Now that you have completed the application process please visit the National Research Ethics Service website > After Review You are invited to give your view of the service that you have received from the National Research Ethics Service and the application procedure. If you wish to make your views known please use the feedback form available on the website. The attached document “After ethical review – guidance for researchers” gives detailed guidance on reporting requirements for studies with a favourable opinion, including:

Notifying substantial amendments

Adding new sites and investigators

Progress and safety reports

Notifying the end of the study

The NRES website also provides guidance on these topics, which is updated in the light of changes in reporting requirements or procedures.

We would also like to inform you that we consult regularly with stakeholders to improve our service. If you would like to join our Reference Group please email referencegroup@nres.npsa.nhs.uk.

09/H1306/58 Please quote this number on all correspondence

With the Committee’s best wishes for the success of this project Yours sincerely Dr John Holmes Chair Email: ann.tunley@leedsth.nhs.uk

Enclosures: List of names and professions of members who were present at the meeting and those who submitted written comments “After ethical review – guidance for researchers”

Copy to: Mrs Clare Skinner, University of Leeds R&D office, Leeds Teaching Hospitals NHS Trust

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Appendix 3: Approval letter received from the University

Research Ethics Committee

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Appendix 4: Survey tool for NHS staff

27 April 2009 Version 7

Questionnaire: Perspectives on Interprofessional Learning and Working

*******

This survey is part of a PhD study which aims to explore how health and social care professions work and learn from each other. As part of this work, I would like to find out about your own training and experiences of working with other professions, as well as your opinions about ‘interprofessional education’ and ‘professional identity’. The survey should take no longer than 10 minutes of your time. All responses will be anonymous, and no attempt will be made to identify you from your responses. If you choose to give your email address at the end of the survey then this information will be stored separately from survey responses.

Alternatively, if you would rather fill out an online version of this questionnaire, you can do so by visiting the following URL:

www.survey.leeds.ac.uk/ipl

Please note that you only need to fill out ONE version of the questionnaire to take part in the research – the online and paper versions of the surveys are identical.

The closing date for this survey is December 30th

2009. Please return your completed

survey by placing it in the stamped addressed envelope provided.

If you would like to know more about the research then you can contact me using the details given below.

Best wishes

Viktoria Joynes, v.c.t.joynes@leeds.ac.uk, 0113 343 6970

Consent:

Please indicate in the box below that you have read the information sheet provided with this survey and that you give your consent to take part in the survey:

Yes No

Section 1: You and your training

1a. Please indicate your profession:

Audiologist

Clinical Physiologist

Dental Nurse

Dentist

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Dietician

Doctor

Midwife

Nurse

Occupational Therapist

Operating Department Practitioner

Optometrist

Pharmacist

Physiotherapist

Podiatrist

Radiographer

Social Worker

Speech and Language Therapist

Other (please specify:)

1b. What specialty or area do you work in?

2. Would you describe your current role as…?

Junior Middle Senior

3. How long ago did you qualify in your chosen profession?

Within the last 12 months

1 – 2 years

3 – 5 years

5 – 10 years

11+ years

4. Where did you undertake your professional training?

United Kingdom

European Union – (including European Economic Area)

Outside the European Union

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5. In which of the following places do you currently a. work and b. supervise, work with or train health or social care students? (please tick all that apply)

Work Work with Students

Acute Trust

Primary Care Trust

Child and Adolescent Mental Health Service

Mental Health Trust

Social care organisation/government organisation

Social enterprise organisation

Voluntary or ‘3rd Sector’ organisation e.g. charity

Private or independent health or social care provider (hospital setting)

Private or independent health or social care provider (community setting)

Educational establishment (e.g. University)

Other (please specify)

6. In your current position, how often do you work with students who are training to become members of your profession?

Never Sometimes Often

I provide an opportunity for students to observe/ learn about my work

I supervise students on placement

I teach students on placement

I am involved in formally assessing students as part of their work-based placements

7. And how often do you work with students who are training to become members of professions other than your own?

Never Sometimes Often

I provide an opportunity for students to observe/ learn about my work

I supervise students on placement

I teach students on placement

I am involved in formally assessing students as part of their work-based placements

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Section 2: Opinions about professional identity

8a. The following questions will ask you about how you feel about your own profession and ‘professional identity’. There are no right or wrong answers – rather, it is your opinion that matters here.

Please indicate one answer for each statement

[SCALE:] Don’t Know - Never – Seldom – Sometimes – Often – Always

i. Being a member of my profession defines who I am

ii. I feel that I “belong” to my profession

iii. I feel I have “strong ties” to my profession

iv. I am pleased to be a member of my profession

If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

8b. Please indicate how much you agree or disagree with the following statements:

[Scale:] Don’t Know - Strongly Disagree – Disagree – Neither Agree nor Disagree – Agree – Strongly Agree

i. I have a clearly defined professional identity and role

ii. I prefer not to be defined by my profession outside of work

iii. The idea of having a ‘professional identity’ is out of date and irrelevant now

If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

Section 3: Your Experiences and Opinions about Interprofessional Education and Working

9a. This survey is interested in finding out your opinions about ‘interprofessional education’. What do YOU think that the term ‘interprofessional education’ means?

9b. And what do you think that the main purpose of interprofessional education is?

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10. Was interprofessional education part of your own professional training? (please tick all that apply)

Yes – in classroom based lessons

Yes – in work or practice-based lessons

No

Don’t Know/Can’t remember

Please feel free to add additional comments:

11a. Do you think that teaching students from different professions together can result in them being better prepared to work in health care teams?

Yes – always

Yes – from classroom teaching only

Yes - from work based/practice based teaching only

No

Don’t Know

11b. Please give a reason for your answer given in 11a:

12. Do you think that interprofessional education should be taught at undergraduate or postgraduate level? (tick all that apply)

-Undergraduate

-Postgraduate

-Don’t know

Additional comments:

13. In your experience, please rate how successful you think interprofessional education can be in achieving the following, with 1 being the least successful and 5 being the most successful:

1 - 2 – 3 – 4 – 5 - No experience

a. Improving communication skills

b. Improving team-working skills

c. Helping students understand their own limitations

d. Improving patient care/service user care

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14. Please indicate how much you agree or disagree with the following statements:

[Scale:] Don’t Know - Strongly Disagree – Disagree – Neither Agree nor Disagree – Agree – Strongly Agree

a. There are tasks that my profession is responsible for which no other profession can undertake

b. At work, I find it easier to communicate with members of my own profession than members of other professions

c. I prefer working with members of my own profession than with members of other professions

d. I feel that members of my profession have the same career opportunities that members of other professions have at work

e. When I work with other members of other professions, my opinion is always listened to and valued

f. I think that there is a lot of respect between professionals at work, regardless of which profession they belong to

g. I think that some professions are given more respect by patients/service users than others

If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

15. Have you heard of the ALPS CETL (Assessment and Learning Practice Settings centre for Excellence in Teaching and Learning) programme?

Yes No

16. If yes, how did you hear about ALPS? (please tick all that apply)

Leaflet or poster

I am, or have been, a member of an ALPS working group

I have been trained to use the ALPS Assessment Tool

I have attended an ALPS workshop

I have attended a conference where ALPS has been represented

Academics who I work with have told me about ALPS

Practice staff who I work with have told me about ALPS

ALPS website

PLF forum

Other (please specify)

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Demographics

17. Are you…

Male Female

18. Please indicate your age

18 – 25

26 – 34

35 – 44

45 – 54

55 or over

Prefer not to say

Thank you for your time. To follow up from this survey I would like to interview people to gain a more in-depth perspective on some of the topics I have asked you about here. If you think you would be interested in taking part in one of these interviews then please fill out your email address in the space provided below:

If you have any queries about this research, or would like to find out about the results of this research when it is complete, please contact me on the details provided below:

Viktoria Joynes, Room 7.09, Worsley Building, University of Leeds

v.c.t.joynes@leeds.ac.uk 0113 3436970

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Appendix 5: Survey tool for academic staff

10th

February 2012 Version 1

Questionnaire: Perspectives on Interprofessional Learning and Working

*******

This survey is part of a PhD study which aims to explore how health and social care professions work and learn from each other. As part of this work, I would like to find out about your own training and experiences of working with other professions, as well as your opinions about ‘interprofessional education’ and ‘professional identity’. The survey should take no longer than 10 minutes of your time. All responses will be anonymous, and no attempt will be made to identify you from your responses. If you choose to give your email address at the end of the survey then this information will be stored separately from survey responses.

Alternatively, if you would rather fill out an online version of this questionnaire, you can do so by visiting the following URL:

www.survey.leeds.ac.uk/hei-ipl

Please note that you only need to fill out ONE version of the questionnaire to take part in the research – the online and paper versions of the surveys are identical.

The closing date for this survey is DATE Please return your completed survey by

placing it in the stamped addressed envelope provided.

If you would like to know more about the research then you can contact me using the details given below.

Best wishes

Viktoria Joynes, v.c.t.joynes@leeds.ac.uk, 0113 343 9211

Consent:

Please indicate in the box below that you have read the information sheet provided with this survey and that you give your consent to take part in the survey:

Yes No

Section 1: You and your training

1a. Please indicate your profession:

Audiologist

Clinical Physiologist

Dental Nurse

Dentist

Dietician

Doctor

319

Midwife

Nurse

Occupational Therapist

Operating Department Practitioner

Optometrist

Pharmacist

Physiotherapist

Podiatrist

Radiographer

Social Worker

Speech and Language Therapist

Other (please specify:)

1b. What specialty or area do you work in?

2. How long ago did you qualify in your chosen profession?

Within the last 12 months

….. years

3. Where did you undertake your professional training?

United Kingdom

European Union – (including European Economic Area)

Outside the European Union

4a. Do you currently work in a Higher Education Institution?

Yes

No

4b. If yes – how long have you worked in Higher Education?

Up to 12 months

…. years

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5. Do you currently still work / actively practice in your chosen profession?

No

Yes – more than once a week

Yes – once a week

Yes – 2-3 times a month

Yes - once a month

Yes – less than once a month

Please provide comments if you wish…

6. In which of the following places do you currently a. work b. supervise or train health or social care students? (please tick all that apply)

Work Supervise or train students

Acute Trust

Primary Care Trust

Child and Adolescent Mental Health Service

Mental Health Trust

Social care organisation/government organisation

Social enterprise organisation

Voluntary or ‘3rd Sector’ organisation e.g. charity

Private or independent health or social care provider (hospital setting)

Private or independent health or social care provider (community setting)

Other health care settings (please specify)

7. In your current position, how often do you work with students who are training to become members of your profession? (please tick one option for each statement)

Never Sometimes Often

I teach students in University-based settings

I provide an opportunity for students to observe/ learn about my work

I supervise students on placement

I teach students on placement

I am involved in formally assessing students as part of their work-based placements

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8. And how often do you work with students who are training to become members of professions other than your own? (please tick one option for each statement)

Never Sometimes Often

I teach students in University-based settings

I provide an opportunity for students to observe/ learn about my work

I supervise students on placement

I teach students on placement

I am involved in formally assessing students as part of their work-based placements

Section 2: Opinions about professional identity

The following questions will ask you about how you feel about your ‘professional identity’. There are no right or wrong answers – rather, it is your opinion that matters here.

9. If asked, would you be more likely to describe your professional identity AT THIS POINT IN TIME as…

A teacher / educator

The health or social care profession in which you are qualified

A mixture of educator and the health or social care profession in which you are qualified

10a. With reference to the HEALTH OR SOCIAL CARE PROFESSION IN WHICH YOU ARE QUALIFIED Please indicate one answer for each statement

[SCALE:] Don’t Know - Never – Seldom – Sometimes – Often – Always

i. Being a member of my profession defines who I am

ii. I feel that I “belong” to my profession

iii. I feel I have “strong ties” to my profession

iv. I am pleased to be a member of my profession

If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

322

10b. With reference to the YOUR TEACHING ROLE Please indicate one answer for

each statement

[SCALE:] Not Applicable - Don’t Know - Never – Seldom – Sometimes – Often – Always

i. Being a member of my profession defines who I am

ii. I feel that I “belong” to my profession

iii. I feel I have “strong ties” to my profession

iv. I am pleased to be a member of my profession

If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

11. Please indicate how much you agree or disagree with the following statements:

[Scale:] Don’t Know - Strongly Disagree – Disagree – Neither Agree nor Disagree – Agree – Strongly Agree

i. I have a clearly defined professional identity and role

ii. I prefer not to be defined by my profession outside of work

iii. The idea of having a ‘professional identity’ is out of date and irrelevant now

If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

Section 3: Your Experiences and Opinions about Interprofessional Education and Working

12a. This survey is interested in finding out your opinions about ‘interprofessional education’. What do YOU think that the term ‘interprofessional education’ means?

12b. And what do you think that the main purpose of interprofessional education is?

13. Was interprofessional education part of your own professional training? (please tick all that apply)

Yes – in classroom based lessons

Yes – as work or practice-based experience

No

Don’t Know/Can’t remember

Please feel free to add additional comments:

323

14a. Do you think that teaching students from different professions together can result in them being better prepared to work in health care teams?

Yes – always

Yes – from classroom teaching only

Yes - through work based/practice based experiences only

No

Don’t Know

14b. Please give a reason for your answer given in 14a:

15. When do you think is the best time for interprofessional education to be introduced? (tick all that apply)

-During undergraduate / pre-registration training

-At postgraduate / post-registration training

-Don’t know

Additional comments:

16. In your experience, please rate how successful you think interprofessional education can be in achieving the following, with 1 being the least successful and 5 being the most successful:

1 - 2 – 3 – 4 – 5 - No experience

a. Improving communication skills

b. Improving team-working skills

c. Helping students understand their own limitations

d. Improving patient care/service user care

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17a. With reference to the HEALTH OR SOCIAL CARE PROFESSION IN WHICH YOU ARE QUALIFIED, please indicate how much you agree or disagree with the following statements:

[Scale:] Don’t Know - Strongly Disagree – Disagree – Neither Agree nor Disagree – Agree – Strongly Agree

a. There are tasks that my profession is responsible for which no other profession can undertake

b. At work, I find it easier to communicate with members of my own profession than members of other professions

c. I prefer working with members of my own profession than with members of other professions

d. I feel that members of my profession have the same career opportunities that members of other professions have at work

e. When I work with other members of other professions, my opinion is always listened to and valued

f. I think that there is a lot of respect between professionals at work, regardless of which profession they belong to

g. I think that some professions are given more respect by patients/service users than others

17b. If you have any comments you would like to make about the answers you have given above, please do so in the space provided below:

18a. Have you ever heard of the ALPS CETL (Assessment and Learning Practice Settings centre for Excellence in Teaching and Learning) programme?

Yes

No

18b. If yes, how did you hear about ALPS? (please tick all that apply)

Leaflet or poster

I was a member of an ALPS working group

I was trained to use the ALPS Assessment Tool

I attended an ALPS workshop

I attended a conference where ALPS was represented

Academics who I work with told me about ALPS

Practice staff who I work with told me about ALPS

ALPS website

PLF forum

Other (please specify)

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Demographics

19. Are you…

Male Female

20. Please indicate your age

18 – 25

26 – 34

35 – 44

45 – 54

55 or over

Prefer not to say

Thank you for your time. To follow up from this survey I would like to interview people to gain a more in-depth perspective on some of the topics I have asked you about here. If you think you would be interested in taking part in one of these interviews then please fill out your email address in the space provided below:

If you have any queries about this research, or would like to find out about the results of this research when it is complete, please contact me on the details provided below:

Viktoria Joynes, Room 14.02, Social Sciences Building, University of Leeds

v.c.t.joynes@leeds.ac.uk 0113 3439211

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Appendix 6: Interview Schedule with NHS staff

Phase 2: Interview Schedule/Topic Guide

Perspectives on Interprofessional Learning and Working

27 April 2009 Version 3

Each participant to be given an information sheet and asked to sign a consent form to show that they are willing to take part in the research, and that they are willing to have their responses recorded and transcribed.

Questions

1. Ask respondent to describe their professional background and their current job role.

2. First of all I’d like to ask you about some of your own experiences of interprofessional education and working. Was there an emphasis on interprofessional education and working as part of your own professional training? [Explore – what, classroom or practice based, which other professions involved, undergraduate or postgraduate]

3a. What sort of interprofessional working do you and your staff engage in now? [Explore – context - is this every day? How easy or difficult is it to define interprofessional working compared to ‘non-interprofessional’ working?]

3b. And do you work or supervise students in practice? [If yes] Are students introduced to interprofessional team working when they come to work in practice? [explore – what knowledge of interprofessional working do students tend to come to their placements with]

4. Interprofessional education aims to improve the communication and team-working skills of those who undertake it – which has the ultimate aim of improving patient (or service user) care. How successful do you think interprofessional education – or working – is in achieving this aim?

5. Are there some professions which you find it easier to work with than others? [Explore - is there an organizational structure which means you end up working with some professions more than others?]

6. A slight change of topic now – thinking a bit more about the idea of ‘professional identity’. Do you feel you have a strong ‘professional identity’? [Explore – do you

327

describe yourself by your profession in and out of work? Is the concept of ‘professional identity’ outdated?]

7. Do you think some health and social care professions have a stronger professional ‘identity’ than others?

8. Do you think professional identity is something that you develop? Or do you think people start their training with a fixed idea of what their ‘professional identity’ will be?

9. I’d like now to talk a little bit about the work of the ALPS CETL and its programme of interprofessional work and assessment. Can you just briefly outline for me how you are involved with ALPS? [Explore – how became involved, how ALPS was introduced in practice]

10. And are you aware of, or have you been involved in, any other large scale interprofessional education initiatives? [Explore – scale of initiatives, how involved].

11. Do you think that ALPS – and similar programmes of work – have, or will – make a difference to the way in which health professionals think about interprofessional education and working?

12. And do you think that an increased amount of focus on interprofessional education will change the way that people think about their professional identity? [Explore – impact on perceptions of health professionals versus perceptions of public/patients/service users].

13. Finally, one of the main aims of ALPS is to introduce a series of generic skills assessments to undergraduates. So for skills such as communication, team-working and ethical practice, the aim is that any student could be assessed by any qualified member of another health and social care profession. I’d be interested to know what you think the benefits and challenges of introducing this interprofessional assessment for generic skills are.

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Appendix 7: Interview Schedule with academic staff

Phase 2: Interview Schedule/Topic Guide

Perspectives on Interprofessional Learning and Working

10th

February 2012 Version 1

Each participant to be given an information sheet and asked to sign a consent form to show that they are willing to take part in the research, and that they are willing to have their responses recorded and transcribed.

Questions

1. What is your current job and professional background? [Explore – teaching role and

h&sc professional background]

2. [Using the responses given in their questionnaire explore…]

a. What do you understand by the term professional identity?

b. How would you describe your own professional identity?

c. Do you feel you have a strong ‘professional identity’?

d. Do you describe yourself by your profession in and out of work?

3. a. How and when do you think that professional identity develops? [Explore if not

mentioned – for students – on courses, on placement etc]

b. At what point do you think your own professional identity ‘formed’? Do you think your professional identity has changed over time? (how/why) [Explore - Who or what were the influences that helped you form this identity?]

c. Were there any specific incidents or times which you think were instrumental in forming your professional identity? Can you describe those to me?

4. In your experience do students have any notion of professional identity when they

apply to do their course? If so, where do you think they get their ideas about this?

5. In your experience do you find some health and social care professions have a stronger professional ‘identity’ than others? [Explore response – why have answered yes or no]

Can you elaborate on your views?

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6. What would you say to the suggestion that the concept of ‘professional identity’ is outdated and irrelevant now? [If required – that people are no longer defined by their work or their professions]

7. I’d now like to ask you about some of your own experiences of interprofessional

education and working.

Was there an emphasis on interprofessional education and working as part of your own professional training? [Explore – what, classroom or practice based, which other professions involved, undergraduate or postgraduate, what sort of experience they had, what did they learn from the IPE setting that was different to the rest of their professional education?]

8. a. What sort of interprofessional working do you engage in now? [Explore – context - is this every day or one-off? Is it through teaching or working in practice?]

b. Are there some professions which you find it easier to work with than others? [Explore – if yes - why? Is there an organizational structure which means you end up working with some professions more than others?]

c. Is any element of interprofessional education offered as either a compulsory or optional part of the course or courses which you teach on now?

d. If yes - what does the IPE consist of? How do the a. students b. other academic staff and c. staff in practice [if relevant] react to it?

9. Do you work with or supervise students in practice? [If yes] Are students introduced to interprofessional team working when they come to work in practice? [explore – what knowledge of interprofessional working do students tend to come to their placements with]

10. Interprofessional education aims to improve the communication and team-working skills of those who undertake it – which has the ultimate aim of improving patient (or service user) care. Do you think interprofessional education can be successful in achieving this aim? If so how?

11. [If relevant] One of the reasons that I became interested in the topic of interprofessional education was that I worked with the ALPS CETL, which involved five universities and sixteen health and social care professions. One of the main aims of ALPS was to introduce interprofessional assessments in a series of generic skills such as communication, team working and ethical practice.

a. Can you remember how you heard about ALPS and were you involved in any of the ALPS initiatives? [Explore – how became involved]

b. Were you involved in introducing any of the ALPS assessments in to practice with students whom you supervised? Is so – can you describe this process? What were the opportunities and challenges involved in this work?

12. Are you aware of, or have you been involved in, any other large scale multi or

interprofessional education initiatives? [Explore – scale of initiatives, how involved].

330

13. Do you think that large scale IPE initiatives such as ALPS – have, or will – make a difference to the way in which health professionals think about their professional working practices?

14. Do you think that ALPS has had any long term legacy for either a. your own professional working practices, b. the academic institutions that were involved in ALPS c. the practice staff who were asked to become involved in the ALPS work [Explore – what and how OR if not, why not]

15. a. And finally do you think that an increased amount of focus on interprofessional education will change the way that people think about their professional identity? [Explore – impact on perceptions of health professionals versus perceptions of public/patients/service users].

b. When would you say is the right time to introduce interprofessional learning? What would you say to the suggestion that introducing IPE too early – or IPE in general, could be perceived as a threat to professional identity formation?

Thank you very much for your time. Do you have any questions for me, or any further comments you would like to make?

331

Appendix 8: Structure of the ALPS Core Team

Director

Oversaw all CETL activity and chaired senior management groups

Programme Manager

Managed Core Team, coordinated and ran all CETL activity

Educational Development Officer (2007 onwards) Developed and ran training for practice staff on use of tools and maps

Project Officer

Supported roll -out of technology and ran training

Research Officer Led and coordinated research and evaluation programme

Mobile Technologies Manager Responsible for procurement of all mobile technology, coordinated roll-out of devices

Learning Development Officer (until 2009) Led on mapping, common competency development, tools and service user engagement

Programme Assistant

Provided administrative support for ALPS Core Team and central CETL

activity

Communications Officer (2009 onwards) Led on external dissemination of ALPS activities

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Appendix 9: ALPS Organisational Structure: Management and Working Groups